Provider Demographics
NPI:1053748749
Name:JEFFERIES, KAMILLIA KASNDRA
Entity type:Individual
Prefix:
First Name:KAMILLIA
Middle Name:KASNDRA
Last Name:JEFFERIES
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 1:4231 TRUMAN DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-8354
Mailing Address - Country:US
Mailing Address - Phone:239-600-9191
Mailing Address - Fax:
Practice Address - Street 1:4231 TRUMAN DR
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-8354
Practice Address - Country:US
Practice Address - Phone:239-600-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2016-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL311ZA0620X
315D00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient