Provider Demographics
NPI:1134772882
Name:TEGNANDER, CAMILLA KRISTIN (MD)
Entity type:Individual
Prefix:
First Name:CAMILLA
Middle Name:KRISTIN
Last Name:TEGNANDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8849
Mailing Address - Country:US
Mailing Address - Phone:337-494-2023
Mailing Address - Fax:337-430-6966
Practice Address - Street 1:1610 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3096
Practice Address - Country:US
Practice Address - Phone:805-924-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA309446390200000X
OK39216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program