Provider Demographics
NPI:1083029987
Name:NEATHERLAND, CAMMIE MAXWELL (NP)
Entity Type:Individual
Prefix:
First Name:CAMMIE
Middle Name:MAXWELL
Last Name:NEATHERLAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CAMMIE
Other - Middle Name:L
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:165 BEECH SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-2059
Mailing Address - Country:US
Mailing Address - Phone:318-259-5646
Mailing Address - Fax:318-259-0019
Practice Address - Street 1:804 CHATHAM AVE
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:LA
Practice Address - Zip Code:71226-8917
Practice Address - Country:US
Practice Address - Phone:318-249-3200
Practice Address - Fax:318-249-3204
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07897363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2375741Medicaid
LA2375741Medicaid