Provider Demographics
NPI:1336789668
Name:JEFFERSON-LIAS, MARECIA SHAFAYE
Entity Type:Individual
Prefix:
First Name:MARECIA
Middle Name:SHAFAYE
Last Name:JEFFERSON-LIAS
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 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:863-229-7970
Mailing Address - Fax:
Practice Address - Street 1:950 COUNTY ROAD 17A W
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-2164
Practice Address - Country:US
Practice Address - Phone:866-234-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004254363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner