Provider Demographics
NPI:1689101305
Name:ARCHER, AYANA MATOKAH
Entity Type:Individual
Prefix:
First Name:AYANA
Middle Name:MATOKAH
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 1:1420 SE 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-9261
Mailing Address - Country:US
Mailing Address - Phone:352-871-5552
Mailing Address - Fax:
Practice Address - Street 1:1420 SE 41ST AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32641-9261
Practice Address - Country:US
Practice Address - Phone:352-871-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012801400Medicaid