Provider Demographics
NPI:1598409815
Name:LEWIS-JOLLEY, EMMANUELLE KONI
Entity Type:Individual
Prefix:MRS
First Name:EMMANUELLE
Middle Name:KONI
Last Name:LEWIS-JOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6860 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-5036
Mailing Address - Country:US
Mailing Address - Phone:727-373-6732
Mailing Address - Fax:
Practice Address - Street 1:6860 66TH ST N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5036
Practice Address - Country:US
Practice Address - Phone:727-373-6732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA94834225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty