Provider Demographics
NPI:1306946694
Name:JEFFERSON, ROSALIE S (ARNP)
Entity type:Individual
Prefix:MS
First Name:ROSALIE
Middle Name:S
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 GRISHAM STREET
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2656
Mailing Address - Country:US
Mailing Address - Phone:407-905-0323
Mailing Address - Fax:407-654-3423
Practice Address - Street 1:12751 W COLONIAL DRIVE
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2656
Practice Address - Country:US
Practice Address - Phone:407-625-6135
Practice Address - Fax:407-654-3423
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL803322363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y5211AMedicare ID - Type Unspecified
P60881Medicare UPIN