=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922129246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN MARIE JEFFRIES RNC, WHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1231 MENOMONIE ST
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-5996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-833-2279
-----------------------------------------------------
Fax | 715-833-8580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19085 64TH AVE
-----------------------------------------------------
City | CHIPPEWA FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54729-6727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | 2860-033
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------