Provider Demographics
NPI:1093482846
Name:ARCHIE, LEEARLIS (CNA, MAA)
Entity Type:Individual
Prefix:
First Name:LEEARLIS
Middle Name:
Last Name:ARCHIE
Suffix:
Gender:F
Credentials:CNA, MAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 STAFFORD PLACE CIRCLE
Mailing Address - Street 2:APT #104
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127
Mailing Address - Country:US
Mailing Address - Phone:336-995-0397
Mailing Address - Fax:336-306-9763
Practice Address - Street 1:1021 STAFFORD PLACE CIRCLE
Practice Address - Street 2:APT #104
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127
Practice Address - Country:US
Practice Address - Phone:336-995-0397
Practice Address - Fax:336-306-9763
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCM108189247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty