MEDICARE: JOLLY A VARGHESE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	692569	CA

General Provider Information

NPI Number	:	1568238103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOLLY A VARGHESE RN

Provider Business Mailing Address
First Line	:	2025 MORSE AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-2115
Country	:	US
Telephone Number	:	916-973-6838
Fax Number	:

Provider Business Practice Location Address
First Line	:	3169 HAYWOOD PL
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95747-9039
Country	:	US
Telephone Number	:	916-256-9609
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2023
Last Update Date	:	11/27/2023

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