Provider Demographics
NPI:1255119772
Name:CAMPBELL, CHEVINE JODIAN
Entity type:Individual
Prefix:
First Name:CHEVINE
Middle Name:JODIAN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 E 228TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4211
Mailing Address - Country:US
Mailing Address - Phone:347-634-0642
Mailing Address - Fax:
Practice Address - Street 1:250 UTICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-3931
Practice Address - Country:US
Practice Address - Phone:718-953-9012
Practice Address - Fax:866-495-5854
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0947589174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist