Provider Demographics
NPI:1427766492
Name:TWENEBOA, EXTA OPPONG
Entity type:Individual
Prefix:
First Name:EXTA
Middle Name:OPPONG
Last Name:TWENEBOA
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 1:160 E COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-2036
Mailing Address - Country:US
Mailing Address - Phone:774-232-4084
Mailing Address - Fax:
Practice Address - Street 1:100 CENTURY DR
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-1244
Practice Address - Country:US
Practice Address - Phone:774-232-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN276084363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health