Healthcare Provider Details

I. General information

NPI: 1568238103
Provider Name (Legal Business Name): JOLLY A VARGHESE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3169 HAYWOOD PL
ROSEVILLE CA
95747-9039
US

IV. Provider business mailing address

2025 MORSE AVE
SACRAMENTO CA
95825-2115
US

V. Phone/Fax

Practice location:
  • Phone: 916-256-9609
  • Fax:
Mailing address:
  • Phone: 916-973-6838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number692569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: