Healthcare Provider Details

I. General information

NPI: 1093962169
Provider Name (Legal Business Name): KRISTIN JOLLIE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 CENTRE OF NEW ENGLAND BLVD
COVENTRY RI
02816-6081
US

IV. Provider business mailing address

8800 SE SUNNYSIDE RD STE 300N
CLACKAMAS OR
97015-5703
US

V. Phone/Fax

Practice location:
  • Phone: 401-822-0423
  • Fax: 401-822-0862
Mailing address:
  • Phone: 281-286-2999
  • Fax: 512-607-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD00164
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: