Provider Demographics
NPI:1427533116
Name:JOLLY, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
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 1:14780 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:855-959-1911
Practice Address - Street 1:1220 W SEASCAPE DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5628
Practice Address - Country:US
Practice Address - Phone:347-225-2627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ217991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily