Provider Demographics
NPI:1124368238
Name:ARCHER, ELIZABETH MARIE
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:ARCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 20TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-3830
Mailing Address - Country:US
Mailing Address - Phone:320-253-5981
Mailing Address - Fax:320-259-1432
Practice Address - Street 1:307 20TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-3830
Practice Address - Country:US
Practice Address - Phone:320-253-5981
Practice Address - Fax:320-259-1432
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN800112-1-RH171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA350025000OtherUMPI