Provider Demographics
NPI:1871291120
Name:JEFFERSON, LAILA
Entity type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:JEFFERSON
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 1:2121 CHIPLEY DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-6990
Mailing Address - Country:US
Mailing Address - Phone:770-670-3155
Mailing Address - Fax:
Practice Address - Street 1:2121 CHIPLEY DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-6990
Practice Address - Country:US
Practice Address - Phone:770-670-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC310680367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse