Provider Demographics
NPI:1427113273
Name:RICHARDS, CAMILLE C (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:C
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:C
Other - Last Name:BERGSTRAESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:601-984-5638
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5678
Practice Address - Fax:601-984-5638
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869001363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04507070Medicaid
MS04507070Medicaid
MS361843YS8TMedicare PIN
MSP01721896Medicare PIN