Provider Demographics
NPI:1215491956
Name:ALTIZER, PENNY MARLENE
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:MARLENE
Last Name:ALTIZER
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:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:NORTH TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24630-0399
Mailing Address - Country:US
Mailing Address - Phone:276-971-1992
Mailing Address - Fax:
Practice Address - Street 1:124 RAYWOOD DR
Practice Address - Street 2:
Practice Address - City:NORTH TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24630-9237
Practice Address - Country:US
Practice Address - Phone:276-971-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator