Provider Demographics
NPI:1639932031
Name:JOLLY, BRIAUNA C (LPN)
Entity Type:Individual
Prefix:
First Name:BRIAUNA
Middle Name:C
Last Name:JOLLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 TAYLOR AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5535
Mailing Address - Country:US
Mailing Address - Phone:706-254-4323
Mailing Address - Fax:
Practice Address - Street 1:5104 TAYLOR AVE APT 2
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5535
Practice Address - Country:US
Practice Address - Phone:706-254-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN076429164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse