Provider Demographics
NPI:1710974969
Name:WIEDEMAN, KAMI WORLEY (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KAMI
Middle Name:WORLEY
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KAMI
Other - Middle Name:LAWRENCE
Other - Last Name:WORLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD STE 355
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:318-966-6800
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:2516 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2988
Practice Address - Country:US
Practice Address - Phone:318-322-7726
Practice Address - Fax:318-322-2614
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03699363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1435082Medicaid
LA383216YJBUMedicare PIN
LA4B482C812OtherMEDICARE CLINIC NUMBER
LA1435082Medicaid
LA4B482Medicare ID - Type UnspecifiedMEDICARE NUMER