Provider Demographics
NPI:1245419423
Name:ARCHIPOV, LYZZA
Entity Type:Individual
Prefix:MRS
First Name:LYZZA
Middle Name:
Last Name:ARCHIPOV
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 1:3487 BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7213
Mailing Address - Country:US
Mailing Address - Phone:239-334-9555
Mailing Address - Fax:239-334-2439
Practice Address - Street 1:3487 BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7213
Practice Address - Country:US
Practice Address - Phone:239-334-9555
Practice Address - Fax:239-334-2439
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator