Healthcare Provider Details

I. General information

NPI: 1336789668
Provider Name (Legal Business Name): MARECIA SHAFAYE JEFFERSON-LIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 COUNTY ROAD 17A W
AVON PARK FL
33825-2164
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 866-234-8534
  • Fax:
Mailing address:
  • Phone: 863-229-7970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11004254
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: