Provider Demographics
NPI:1356620629
Name:CAPTAIN, CHETAUN C
Entity type:Individual
Prefix:
First Name:CHETAUN
Middle Name:C
Last Name:CAPTAIN
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 1:10260 PEACOCK LN
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-0876
Mailing Address - Country:US
Mailing Address - Phone:937-367-3058
Mailing Address - Fax:
Practice Address - Street 1:10260 PEACOCK LN
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-0876
Practice Address - Country:US
Practice Address - Phone:937-367-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN145064164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse