MEDICARE: TAWANDA JOLLLY INDEPENDANT PROVIDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	0295563	OH

General Provider Information

NPI Number	:	1366044208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAWANDA JOLLLY INDEPENDANT PROVIDER

Provider Business Mailing Address
First Line	:	4126 E 110TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44105-5325
Country	:	US
Telephone Number	:	216-203-6053
Fax Number	:

Provider Business Practice Location Address
First Line	:	4126 E 110TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44105-5325
Country	:	US
Telephone Number	:	216-203-6053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2020
Last Update Date	:	11/16/2020

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