Basic Information
Provider Information | |||||||||
NPI: | 1124472519 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEFFERIS | ||||||||
FirstName: | MILES | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 62301 BIRCH DR | ||||||||
Address2: |   | ||||||||
City: | BARNESVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 437139757 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405796737 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BARNESVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 437131005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7402396447 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2016 | ||||||||
LastUpdateDate: | 09/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.384821 | OH | N |   | Nursing Service Providers | Registered Nurse |   | 163WP2201X | 84913 | WV | N |   | Nursing Service Providers | Registered Nurse | Ambulatory Care | 363LF0000X | CNP.0027120 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN.CNP.107143 | WV | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.