Provider Demographics
NPI:1922762574
Name:UCLARAY, JOLLY ANNE LORENZO
Entity Type:Individual
Prefix:
First Name:JOLLY ANNE
Middle Name:LORENZO
Last Name:UCLARAY
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 1:770 LONO AVE
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2531
Mailing Address - Country:US
Mailing Address - Phone:808-205-4815
Mailing Address - Fax:
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-442-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV842545163W00000X
HIAPRN-3428-0363L00000X
HI54970163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI08142002Medicaid