Provider Demographics
NPI:1396031951
Name:JOLLY, AMANDA ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:JOLLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ELIZABETH
Other - Last Name:SCHUSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2485 LINEVILLE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7140
Mailing Address - Country:US
Mailing Address - Phone:920-857-3700
Mailing Address - Fax:920-857-3888
Practice Address - Street 1:2485 LINEVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7140
Practice Address - Country:US
Practice Address - Phone:920-857-3700
Practice Address - Fax:920-857-3888
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3229-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist