Provider Demographics
NPI:1154054609
Name:AGYEPONG, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:AGYEPONG
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 1:2520 WINDY HILL RD SE STE 301
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 HUNTINGTON PLACE CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8651
Practice Address - Country:US
Practice Address - Phone:678-782-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2024-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty