Provider Demographics
NPI:1396161535
Name:ARCHIE, ANNETTE
Entity type:Individual
Prefix:MISS
First Name:ANNETTE
Middle Name:
Last Name:ARCHIE
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 1:15508 WESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2122
Mailing Address - Country:US
Mailing Address - Phone:216-752-0906
Mailing Address - Fax:216-752-1910
Practice Address - Street 1:15508 WESTVIEW AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2122
Practice Address - Country:US
Practice Address - Phone:216-752-0906
Practice Address - Fax:216-752-1910
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2553857Medicaid