Provider Demographics
NPI:1669543203
Name:BOUTWELL, TERESA (CST)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1938
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-7291
Mailing Address - Country:US
Mailing Address - Phone:770-985-4257
Mailing Address - Fax:770-985-4258
Practice Address - Street 1:70 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:GA
Practice Address - Zip Code:30054-4648
Practice Address - Country:US
Practice Address - Phone:770-985-4257
Practice Address - Fax:770-985-4258
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA91956363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical