Provider Demographics
NPI:1649975731
Name:ANTWI, MATILDA MABEL (NP)
Entity type:Individual
Prefix:MS
First Name:MATILDA
Middle Name:MABEL
Last Name:ANTWI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:MATILDA
Other - Middle Name:MABEL
Other - Last Name:ANTWI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:715 RIVER RUSH DR # 715
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7465
Mailing Address - Country:US
Mailing Address - Phone:630-202-6958
Mailing Address - Fax:
Practice Address - Street 1:715 RIVER RUSH DR
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-7465
Practice Address - Country:US
Practice Address - Phone:630-202-6958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF03230449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine