MEDICARE: PATTIELASHAWN JEFFERIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703123420	MI

General Provider Information

NPI Number	:	1861202590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATTIELASHAWN JEFFERIES

Provider Business Mailing Address
First Line	:	129 PHEASANT LN
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8188
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	129 PHEASANT LN
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8188
Country	:	US
Telephone Number	:	810-336-1261
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2025
Last Update Date	:	01/14/2025

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