Provider Demographics
NPI:1184274896
Name:NJU, MATILDA N
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:N
Last Name:NJU
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 1:41 KELSO WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-2618
Mailing Address - Country:US
Mailing Address - Phone:678-457-7790
Mailing Address - Fax:
Practice Address - Street 1:41 KELSO WAY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-2618
Practice Address - Country:US
Practice Address - Phone:678-457-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-14
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224893363L00000X
GAF09190189208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist