Provider Demographics
NPI:1306985833
Name:EARL, NICOLE M (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:EARL
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2849 MICHIGAN ST NE STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1216
Mailing Address - Country:US
Mailing Address - Phone:616-285-6450
Mailing Address - Fax:616-285-6455
Practice Address - Street 1:2849 MICHIGAN ST NE STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-285-6450
Practice Address - Fax:616-285-6455
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2019-05-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant