Provider Demographics
NPI:1184237000
Name:JEFFERSON, DESTINY LAINE
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:LAINE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 CREEKS EDGE LN
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-8666
Mailing Address - Country:US
Mailing Address - Phone:228-282-3236
Mailing Address - Fax:
Practice Address - Street 1:2721 CREEKS EDGE LN
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-8666
Practice Address - Country:US
Practice Address - Phone:228-282-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily