Provider Demographics
NPI:1629517099
Name:FRITZ, LETITIA BOBBETTE
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:BOBBETTE
Last Name:FRITZ
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 1:105 W STONE DR STE 6A
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3256
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:1905 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5882
Practice Address - Country:US
Practice Address - Phone:423-230-8160
Practice Address - Fax:423-230-8416
Is Sole Proprietor?:No
Enumeration Date:2017-02-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174677363LF0000X
TN22241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVO25B288Medicare PIN
TN103I501343Medicare PIN