Individual
TERESA BOUTWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CST
Contact information
Practice address
70 ASHFORD DR, OXFORD, GA 30054-4648
(770) 985-4257
(770) 985-4258
Mailing address
PO BOX 1938, CONYERS, GA 30012-7291
(770) 985-4257
(770) 985-4258
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
91956
GA
Other
Enumeration date
11/13/2006
Last updated
07/08/2007
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