Basic Information
| Provider Information | |||||||||
| NPI: | 1013949213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | CAMILLE | ||||||||
| MiddleName: | THOMPSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 620 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710403202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189272024 | ||||||||
| FaxNumber: | 3189273547 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 MORRIS CIR | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710402100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189271110 | ||||||||
| FaxNumber: | 3189271116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN078196 AP04243 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1721123 | 05 | LA | MEDICAID |