Healthcare Provider Details

I. General information

NPI: 1548770944
Provider Name (Legal Business Name): TYLER RUSSELL ARCHER MSN, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DUNHILL PL NW
CLEVELAND TN
37311
US

IV. Provider business mailing address

102 DUNHILL PL NW
CLEVELAND TN
37311-3885
US

V. Phone/Fax

Practice location:
  • Phone: 423-339-9581
  • Fax: 423-472-0494
Mailing address:
  • Phone: 423-476-5774
  • Fax: 423-472-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23287
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: