Provider Demographics
NPI:1982652608
Name:JOLLY, YVONNE C (RN, MS, ANPC)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:C
Last Name:JOLLY
Suffix:
Gender:F
Credentials:RN, MS, ANPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 ROUTES 5 & 20
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456
Mailing Address - Country:US
Mailing Address - Phone:315-789-5758
Mailing Address - Fax:315-789-0741
Practice Address - Street 1:1150 ROUTES 5 & 20
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456
Practice Address - Country:US
Practice Address - Phone:315-789-5758
Practice Address - Fax:315-789-0741
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301742363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02509240Medicaid
NY000923698003OtherHEALTHNOW ID#
NYP019301742OtherBLUE CHOICE ID#
NY109133BOOtherPREFERRED CARE ID#
NY000923698003OtherHEALTHNOW ID#
NY02509240Medicaid