Provider Demographics
NPI:1346771961
Name:ALTIZER-COMPTON, LETONYA SHERYL
Entity Type:Individual
Prefix:MRS
First Name:LETONYA
Middle Name:SHERYL
Last Name:ALTIZER-COMPTON
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 1:220 CLAY DR
Mailing Address - Street 2:
Mailing Address - City:POUNDING MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24637-4320
Mailing Address - Country:US
Mailing Address - Phone:276-963-3606
Mailing Address - Fax:276-963-3747
Practice Address - Street 1:220 CLAY DR
Practice Address - Street 2:
Practice Address - City:POUNDING MILL
Practice Address - State:VA
Practice Address - Zip Code:24637-4320
Practice Address - Country:US
Practice Address - Phone:276-963-3606
Practice Address - Fax:276-963-3747
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA13963672251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54-1620121Medicaid