Provider Demographics
NPI:1750104733
Name:JOLLY, ROSHEEDA
Entity type:Individual
Prefix:
First Name:ROSHEEDA
Middle Name:
Last Name:JOLLY
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 1:4000 HEATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TX
Mailing Address - Zip Code:75009-0947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 HEATHERTON DR
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TX
Practice Address - Zip Code:75009-0947
Practice Address - Country:US
Practice Address - Phone:214-727-6899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX152242367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered