Healthcare Provider Details

I. General information

NPI: 1669543203
Provider Name (Legal Business Name): TERESA BOUTWELL CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 ASHFORD DR
OXFORD GA
30054-4648
US

IV. Provider business mailing address

PO BOX 1938
CONYERS GA
30012-7291
US

V. Phone/Fax

Practice location:
  • Phone: 770-985-4257
  • Fax: 770-985-4258
Mailing address:
  • Phone: 770-985-4257
  • Fax: 770-985-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number91956
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: