Provider Demographics
NPI:1639910482
Name:CELESTINE, VANKETTIA RENELL
Entity type:Individual
Prefix:
First Name:VANKETTIA
Middle Name:RENELL
Last Name:CELESTINE
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 1:4811 SUMMERHILL DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-2011
Mailing Address - Country:US
Mailing Address - Phone:708-785-3528
Mailing Address - Fax:
Practice Address - Street 1:1934 W 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-5268
Practice Address - Country:US
Practice Address - Phone:708-785-3528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company