Provider Demographics
NPI:1982399556
Name:JEFFERY, FUNMILAYO BETHANY
Entity Type:Individual
Prefix:
First Name:FUNMILAYO
Middle Name:BETHANY
Last Name:JEFFERY
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 1:13520 MCLEAREN RD UNIT 711112
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-8046
Mailing Address - Country:US
Mailing Address - Phone:855-933-2388
Mailing Address - Fax:
Practice Address - Street 1:1954 OPITZ BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3304
Practice Address - Country:US
Practice Address - Phone:703-492-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001312747163W00000X
VA0024187026363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse