Provider Demographics
NPI:1962905950
Name:JOLLY, NANCY ELLEN (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:ELLEN
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 1:214 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-9153
Mailing Address - Country:US
Mailing Address - Phone:270-522-0898
Mailing Address - Fax:
Practice Address - Street 1:214 MAIN ST
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-9153
Practice Address - Country:US
Practice Address - Phone:270-522-0898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYJ09-873-354390200000X
KY56759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program