Healthcare Provider Details

I. General information

NPI: 1649324930
Provider Name (Legal Business Name): ATHENA T JOLLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1909
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD SUITE 1K
WILLIAMSPORT PA
17701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 570-320-7444
  • Fax: 570-320-7445
Mailing address:
  • Phone: 570-326-8723
  • Fax: 570-326-8922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0000709
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD043019E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD043019E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: