Provider Demographics
NPI:1831153733
Name:JOLLY, KIM D (ARNP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:D
Last Name:JOLLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-759-7557
Mailing Address - Fax:954-733-9155
Practice Address - Street 1:3716 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-1134
Practice Address - Country:US
Practice Address - Phone:954-759-7557
Practice Address - Fax:954-733-9155
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2005522363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034297100Medicaid
FLY7912ZMedicare ID - Type Unspecified