Provider Demographics
NPI:1538106802
Name:JOLLY, ALLENE CRAVEN (CRNA)
Entity Type:Individual
Prefix:
First Name:ALLENE
Middle Name:CRAVEN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 CORDER DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6210
Mailing Address - Country:US
Mailing Address - Phone:662-284-9995
Mailing Address - Fax:662-284-9920
Practice Address - Street 1:3050 CORDER DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6210
Practice Address - Country:US
Practice Address - Phone:662-284-9995
Practice Address - Fax:662-284-9920
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2723082367500000X
MSR529109367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306470100Medicaid
MS09659357Medicaid
FLG3584OtherBCBS
MSR35074Medicare UPIN
MS430002154Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #
FL306470100Medicaid