Provider Demographics
NPI:1457669012
Name:JEFFRIES, ANTWAN LAVEE (STNA)
Entity Type:Individual
Prefix:MR
First Name:ANTWAN
Middle Name:LAVEE
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 GAWIL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-1116
Mailing Address - Country:US
Mailing Address - Phone:419-787-0139
Mailing Address - Fax:
Practice Address - Street 1:616 GAWIL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-1116
Practice Address - Country:US
Practice Address - Phone:419-787-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401111130710376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide