Provider Demographics
NPI:1184231417
Name:ARCHER, SAMANTHA BETTY LEE I
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:BETTY LEE
Last Name:ARCHER
Suffix:I
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:BETTY LEE
Other - Last Name:ARCHER
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1275 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4228
Mailing Address - Country:US
Mailing Address - Phone:717-781-7551
Mailing Address - Fax:
Practice Address - Street 1:900 N JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2117
Practice Address - Country:US
Practice Address - Phone:765-494-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer