Provider Demographics
NPI:1154474369
Name:JOLY, NICHOLE KRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:KRISTINE
Last Name:JOLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:KRISTINE
Other - Last Name:GREULICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:3800 RESERVOIR RD NW
Mailing Address - Street 2:4PHC
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2113
Mailing Address - Country:US
Mailing Address - Phone:202-444-5022
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:4PHC
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-444-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010809363AS0400X
DCPA031121363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400041043Medicare UPIN
NYA400036739Medicare PIN
NYA400041044Medicare PIN