Provider Demographics
NPI:1306571468
Name:BOACHIE, MATILDA (PMHNP)
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:
Last Name:BOACHIE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:MATILDA
Other - Middle Name:
Other - Last Name:EDZIEGBE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:316 W PINNACLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-7047
Mailing Address - Country:US
Mailing Address - Phone:860-967-2388
Mailing Address - Fax:
Practice Address - Street 1:316 W PINNACLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7047
Practice Address - Country:US
Practice Address - Phone:860-967-2388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2347282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA