Provider Demographics
NPI:1902094394
Name:ROSALIE A JEFFERSON, P.A.
Entity Type:Organization
Organization Name:ROSALIE A JEFFERSON, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDIENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:407-625-0135
Mailing Address - Street 1:718 GRISHAM ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2656
Mailing Address - Country:US
Mailing Address - Phone:407-625-6135
Mailing Address - Fax:
Practice Address - Street 1:718 GRISHAM ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2656
Practice Address - Country:US
Practice Address - Phone:407-625-6135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80332-2363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP60881Medicare UPIN
FLK4844Medicare PIN