Basic Information
| Provider Information | |||||||||
| NPI: | 1144680364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | PREETHY | ||||||||
| MiddleName: | KOOTHUR | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JOHN | ||||||||
| OtherFirstName: | PREETHY | ||||||||
| OtherMiddleName: | KOOTHUR | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1426 THREEPINE PL SW | ||||||||
| Address2: | |||||||||
| City: | LILBURN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300475681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042917040 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 275 COLLIER RD NW | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046052800 | ||||||||
| FaxNumber: | 4043515983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2016 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN161615 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.