Healthcare Provider Details

I. General information

NPI: 1174218622
Provider Name (Legal Business Name): KELLY JOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 7TH AVE S
BIRMINGHAM AL
35233-1711
US

IV. Provider business mailing address

PO BOX 55310
BIRMINGHAM AL
35255-5310
US

V. Phone/Fax

Practice location:
  • Phone: 205-249-4542
  • Fax:
Mailing address:
  • Phone: 205-731-9701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-100459
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-100459
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: