Provider Demographics
NPI:1942371661
Name:JOLLON, MARILYN ANN (CNM)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:ANN
Last Name:JOLLON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 NASSAU RD
Mailing Address - Street 2:LONG ISLAND FQHC, INC.
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1343
Mailing Address - Country:US
Mailing Address - Phone:516-571-8600
Mailing Address - Fax:
Practice Address - Street 1:380 NASSAU RD
Practice Address - Street 2:LONG ISLAND FQHC, INC.
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1343
Practice Address - Country:US
Practice Address - Phone:516-571-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000637367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00330128Medicare ID - Type Unspecified