Provider Demographics
NPI:1326003377
Name:JEFFRESS, MARY PAIGE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PAIGE
Last Name:JEFFRESS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 S DENALI PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8103
Mailing Address - Country:US
Mailing Address - Phone:208-288-1229
Mailing Address - Fax:
Practice Address - Street 1:4750 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2715
Practice Address - Country:US
Practice Address - Phone:208-375-0500
Practice Address - Fax:208-375-4310
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN00541363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2407007Medicaid
NV2407007Medicaid
NV34845Medicare PIN