Provider Demographics
NPI:1861482762
Name:ARCHER, KATHLEEN A (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:ARCHER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8258 HASCALL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124
Mailing Address - Country:US
Mailing Address - Phone:402-391-3010
Mailing Address - Fax:402-391-3076
Practice Address - Street 1:11820 STANDING STONE DR
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-7979
Practice Address - Country:US
Practice Address - Phone:402-332-3903
Practice Address - Fax:402-391-3076
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0462945Medicaid
IA0462945Medicaid