Provider Demographics
NPI:1902079957
Name:BROCKETT, CAMILLE TISHA (NP)
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:TISHA
Last Name:BROCKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 AUSTIN LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EMORY UNIVERSITY HOSPITAL EMERGENCY DEPARTMENT
Practice Address - Street 2:1364 CLIFFTON ROAD
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1006
Practice Address - Country:US
Practice Address - Phone:404-712-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184254363LF0000X
GARN184254NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily