Provider Demographics
NPI:1073275939
Name:JOLLY, KEONA MARIE
Entity Type:Individual
Prefix:
First Name:KEONA
Middle Name:MARIE
Last Name:JOLLY
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 1:6224 JANICE PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1842
Mailing Address - Country:US
Mailing Address - Phone:937-287-6272
Mailing Address - Fax:
Practice Address - Street 1:6224 JANICE PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1842
Practice Address - Country:US
Practice Address - Phone:937-287-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No251E00000XAgenciesHome Health