Provider Demographics
NPI:1407214315
Name:ARCHAMBAULT, NICOLE JOAN (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JOAN
Last Name:ARCHAMBAULT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 HANSEN CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-7450
Mailing Address - Country:US
Mailing Address - Phone:906-367-0448
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH ST STE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-935-5800
Practice Address - Fax:231-935-5799
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007654363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical