Provider Demographics
NPI:1033777826
Name:THOMAS, JOLLY MARIA (NP)
Entity Type:Individual
Prefix:MRS
First Name:JOLLY
Middle Name:MARIA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JOLLY
Other - Middle Name:AUGUSTINE
Other - Last Name:POTTAMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN
Mailing Address - Street 1:1867 ANTHONY NANE CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3991
Mailing Address - Country:US
Mailing Address - Phone:404-213-3698
Mailing Address - Fax:
Practice Address - Street 1:1867 ANTHONY NANE CT
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3991
Practice Address - Country:US
Practice Address - Phone:404-213-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN190105363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology