Provider Demographics
NPI:1053081398
Name:ANTWI, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ANTWI
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 1:1331 BURNSIDE AVE APT A4
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1577
Mailing Address - Country:US
Mailing Address - Phone:240-408-0736
Mailing Address - Fax:
Practice Address - Street 1:1331 BURNSIDE AVE APT A4
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-1577
Practice Address - Country:US
Practice Address - Phone:240-408-0736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT105066363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health