Desarae Lateva Jefferson
Individual provider Active NPI Private Vehicle · Hurt, VA
NPI 1114559077 · NPPES record last updated Feb 10, 2020
Key facts
- NPI
- 1114559077
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Private Vehicle 347C00000X
- License
- T60727635 (VA)
- Practice address
- 4357 Roark Mill Rd
Hurt, VA 24563-3308 - Phone
- (434) 420-8823
- Fax
- (434) 324-0568
- NPI assigned
- Feb 10, 2020
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| T60727635 | VA | MD | Private Vehicle |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Private Vehicle | 347C00000X | T60727635 | VA | Yes |
Addresses
Primary practice location
4357 Roark Mill Rd
Hurt, VA 24563-3308
Mailing address
4357 Roark Mill Rd
Hurt, VA 24563-3308
Phone (434) 420-8823
Other providers in Hurt, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 10, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.