Provider Demographics
NPI:1093056038
Name:JOLLY, MARY SULLIVAN (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SULLIVAN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2140
Mailing Address - Street 2:
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-2140
Mailing Address - Country:US
Mailing Address - Phone:270-522-6963
Mailing Address - Fax:270-522-7231
Practice Address - Street 1:250 MAIN STREET, SUITE E
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211
Practice Address - Country:US
Practice Address - Phone:270-522-6963
Practice Address - Fax:270-522-7231
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily