Provider Demographics
NPI:1194402073
Name:ALTIDOR, BENITA (NP)
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:ALTIDOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:513-873-1269
Mailing Address - Fax:
Practice Address - Street 1:101 N LYNNHAVEN RD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7523
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024187421363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner