Provider Demographics
NPI:1508390873
Name:ARCHER, KAITLIN ELIZABETH
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ELIZABETH
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 1:28 CROYDON AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1927
Mailing Address - Country:US
Mailing Address - Phone:631-428-6879
Mailing Address - Fax:
Practice Address - Street 1:28 CROYDON AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-1927
Practice Address - Country:US
Practice Address - Phone:631-428-6879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325513164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse