Provider Demographics
NPI:1619412004
Name:JOLLY, TINA (MSN, APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BLUE RIDGE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4431
Mailing Address - Country:US
Mailing Address - Phone:706-946-5607
Mailing Address - Fax:706-374-7628
Practice Address - Street 1:165 BLUE RIDGE OVERLOOK
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4431
Practice Address - Country:US
Practice Address - Phone:706-946-4647
Practice Address - Fax:706-374-5006
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1619412004Medicaid
TNQ071116Medicaid
GA003151473DMedicaid