Provider Demographics
NPI:1700916095
Name:CHURCHMAN, NICHOLE MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:MICHELLE
Last Name:CHURCHMAN
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 1:1017 W FERTITTA BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4646
Mailing Address - Country:US
Mailing Address - Phone:337-238-4511
Mailing Address - Fax:337-238-4513
Practice Address - Street 1:1017 W FERTITTA BLVD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4646
Practice Address - Country:US
Practice Address - Phone:337-238-4511
Practice Address - Fax:337-238-4513
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1073776Medicaid
LA1073776Medicaid