Basic Information
| Provider Information | |||||||||
| NPI: | 1407813090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | VONETTA | ||||||||
| MiddleName: | CHARLENE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 MARCELLA RD | ||||||||
| Address2: | STE A | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236662578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575944006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2855 DENBIGH BLVD | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236926501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579685700 | ||||||||
| FaxNumber: | 7575942195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101238688 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010339910 | 05 | VA | MEDICAID |