Provider Demographics
NPI:1093223570
Name:JOLLY, SAMANTHA (FNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CLARION CT
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-1604
Mailing Address - Country:US
Mailing Address - Phone:302-290-7225
Mailing Address - Fax:
Practice Address - Street 1:5936 LIMESTONE RD
Practice Address - Street 2:
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-8930
Practice Address - Country:US
Practice Address - Phone:302-235-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0001105363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care