Provider Demographics
NPI:1225018914
Name:DEFIBAUGH, JILL T (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:T
Last Name:DEFIBAUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913 VALLEY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2676
Mailing Address - Country:US
Mailing Address - Phone:540-678-0792
Mailing Address - Fax:540-678-0795
Practice Address - Street 1:2913 VALLEY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2676
Practice Address - Country:US
Practice Address - Phone:540-678-0792
Practice Address - Fax:540-678-0795
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166690363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010211417Medicaid
VA289215OtherANTHEM BCBS
WV3810003821Medicaid
VA001788730OtherMOUNTAIN STATE BCBS
VAQ57909Medicare UPIN
VA009172W35Medicare PIN