Provider Demographics
NPI:1407523376
Name:WITHERELL, CHRISTIE MARIE
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:MARIE
Last Name:WITHERELL
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 1:454 J J LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-6989
Mailing Address - Country:US
Mailing Address - Phone:985-774-8409
Mailing Address - Fax:
Practice Address - Street 1:2OO HENRY CLAY AVENUE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118
Practice Address - Country:US
Practice Address - Phone:504-380-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA221362363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal