Provider Demographics
NPI:1629251145
Name:DALLMIER, JOLLY MICHELE (NP)
Entity Type:Individual
Prefix:
First Name:JOLLY
Middle Name:MICHELE
Last Name:DALLMIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W TEMPLE AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2121
Mailing Address - Country:US
Mailing Address - Phone:217-342-0211
Mailing Address - Fax:217-342-0232
Practice Address - Street 1:900 W TEMPLE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2121
Practice Address - Country:US
Practice Address - Phone:217-342-0211
Practice Address - Fax:217-342-0232
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-000147OtherLICENSE
ILP00465586OtherRAILROAD MEDICARE/PALMETTO GBA
IL209-000147OtherLICENSE
IL210756Medicare PIN
ILK13866Medicare PIN