Provider Demographics
NPI:1558691584
Name:HOUSTON, LETITIA LORRAINE
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:LORRAINE
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LETITIA
Other - Middle Name:LORRAINE
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2039 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1459
Mailing Address - Country:US
Mailing Address - Phone:706-324-2485
Mailing Address - Fax:706-327-9769
Practice Address - Street 1:2039 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1459
Practice Address - Country:US
Practice Address - Phone:706-324-2485
Practice Address - Fax:706-327-9769
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003447363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant