Provider Demographics
NPI:1245756964
Name:LETT, DEXTER SHABAZZ (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:SHABAZZ
Last Name:LETT
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 WINESAP DR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-5147
Mailing Address - Country:US
Mailing Address - Phone:804-219-9519
Mailing Address - Fax:804-293-3934
Practice Address - Street 1:6960 FOREST HILL AVE STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1606
Practice Address - Country:US
Practice Address - Phone:804-219-9519
Practice Address - Fax:804-293-3934
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2024-01-29
Deactivation Date:2022-05-17
Deactivation Code:
Reactivation Date:2022-06-14
Provider Licenses
StateLicense IDTaxonomies
VA0001228602163W00000X
VA0024184489363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse