Provider Demographics
NPI:1740061209
Name:AZOR-ANTOINE, EDWIDGE
Entity type:Individual
Prefix:
First Name:EDWIDGE
Middle Name:
Last Name:AZOR-ANTOINE
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 1:100 GREENWAY BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4358
Mailing Address - Country:US
Mailing Address - Phone:770-812-8825
Mailing Address - Fax:770-812-5910
Practice Address - Street 1:706 DIXIE ST STE 220
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3889
Practice Address - Country:US
Practice Address - Phone:770-812-8825
Practice Address - Fax:770-812-5910
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA302190363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics