Provider Demographics
NPI:1780724260
Name:JOLLY, VALERIE NICOLE (MD)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:NICOLE
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 12TH AVE NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5761
Mailing Address - Country:US
Mailing Address - Phone:580-223-3216
Mailing Address - Fax:580-223-4184
Practice Address - Street 1:731 12TH AVE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5761
Practice Address - Country:US
Practice Address - Phone:580-223-3216
Practice Address - Fax:580-223-4184
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6397208600000X
OK24633208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB104645Medicare PIN