Basic Information
| Provider Information | |||||||||
| NPI: | 1346771961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTIZER-COMPTON | ||||||||
| FirstName: | LETONYA | ||||||||
| MiddleName: | SHERYL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 CLAY DR | ||||||||
| Address2: | |||||||||
| City: | POUNDING MILL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246374320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769633606 | ||||||||
| FaxNumber: | 2769633747 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 CLAY DR | ||||||||
| Address2: | |||||||||
| City: | POUNDING MILL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246374320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769633606 | ||||||||
| FaxNumber: | 2769633747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2017 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 13963672 | VA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 54-1620121 | 05 | VA | MEDICAID |