Provider Demographics
NPI:1316930746
Name:JOLLY, NANCY PUTNAM (ANP-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:PUTNAM
Last Name:JOLLY
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N DEKALB ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3911
Mailing Address - Country:US
Mailing Address - Phone:704-482-1482
Mailing Address - Fax:704-480-6012
Practice Address - Street 1:711 N DEKALB ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3911
Practice Address - Country:US
Practice Address - Phone:704-482-1482
Practice Address - Fax:704-480-6012
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900397363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8958513Medicaid
2809106Medicare ID - Type Unspecified
P96312Medicare UPIN