Healthcare Provider Details

I. General information

NPI: 1760170765
Provider Name (Legal Business Name): CAMILLE JEFFERSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SE 3RD ST
TRENTON FL
32693-3247
US

IV. Provider business mailing address

25352 NW 10TH AVE
NEWBERRY FL
32669-2569
US

V. Phone/Fax

Practice location:
  • Phone: 352-577-5252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11021893
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: