Provider Demographics
NPI:1487296034
Name:PERSON, ARCHIE III (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:ARCHIE
Middle Name:
Last Name:PERSON
Suffix:III
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 LOCKMEADE WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8185
Mailing Address - Country:US
Mailing Address - Phone:706-587-0716
Mailing Address - Fax:
Practice Address - Street 1:7933 IVY PARK DR
Practice Address - Street 2:
Practice Address - City:FORTSON
Practice Address - State:GA
Practice Address - Zip Code:31808-6870
Practice Address - Country:US
Practice Address - Phone:706-587-0716
Practice Address - Fax:706-587-0716
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN221260363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care