Provider Demographics
NPI:1366044208
Name:JOLLLY, TAWANDA (INDEPENDANT PROVIDER)
Entity Type:Individual
Prefix:
First Name:TAWANDA
Middle Name:
Last Name:JOLLLY
Suffix:
Gender:F
Credentials:INDEPENDANT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4126 E 110TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5325
Mailing Address - Country:US
Mailing Address - Phone:216-203-6053
Mailing Address - Fax:
Practice Address - Street 1:4126 E 110TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5325
Practice Address - Country:US
Practice Address - Phone:216-203-6053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0295563376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty