Provider Demographics
NPI:1831769322
Name:JOLLY, EGLIN GLORIANA
Entity type:Individual
Prefix:
First Name:EGLIN
Middle Name:GLORIANA
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 1:1421 MARYLAND AVE NE # 1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-5036
Mailing Address - Country:US
Mailing Address - Phone:202-386-9821
Mailing Address - Fax:
Practice Address - Street 1:1421 MARYLAND AVE NE # 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-5036
Practice Address - Country:US
Practice Address - Phone:202-386-9821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant