Provider Demographics
NPI:1720230766
Name:ARCHIBALD, KATHY D (GCNS)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:D
Last Name:ARCHIBALD
Suffix:
Gender:F
Credentials:GCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-0335
Mailing Address - Country:US
Mailing Address - Phone:208-235-5910
Mailing Address - Fax:208-235-5920
Practice Address - Street 1:2302 E TERRY ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2733
Practice Address - Country:US
Practice Address - Phone:208-235-5910
Practice Address - Fax:208-235-5920
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNS45A364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1341125Medicare PIN