=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134930027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYDNEY ROSE JOLLIFF FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2025
-----------------------------------------------------
Last Update Date | 01/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1332 N 7TH ST
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-238-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4937 WABASH AVE
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47803-1447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-244-9359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71016231A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------