Provider Demographics
NPI:1194360578
Name:JOLLY, ALEX (APRN)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:JOLLY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3804
Mailing Address - Country:US
Mailing Address - Phone:270-570-0379
Mailing Address - Fax:
Practice Address - Street 1:425 E 20TH ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3804
Practice Address - Country:US
Practice Address - Phone:270-570-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014042207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine