Basic Information
| Provider Information | |||||||||
| NPI: | 1245756964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LETT | ||||||||
| FirstName: | DEXTER | ||||||||
| MiddleName: | SHABAZZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10543 S CRATER RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH PRINCE GEORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238057333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044315585 | ||||||||
| FaxNumber: | 8044315820 | ||||||||
| Practice Location | |||||||||
| Address1: | 10543 S. CRATER RD | ||||||||
| Address2: | |||||||||
| City: | S. PRINCE GEORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044315585 | ||||||||
| FaxNumber: | 8044315820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/17/2022 | ||||||||
| NPIReactivationDate: | 06/14/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001228602 | VA | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 0024184489 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.