Individual
DR. ATHENA T JOLLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1100 GRAMPIAN BLVD, WILLIAMSPORT, PA 17701-1909
(570) 320-7444
(570) 320-7445
Mailing address
1201 GRAMPIAN BLVD, SUITE 1K, WILLIAMSPORT, PA 17701-1900
(570) 326-8723
(570) 326-8922
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
C1-0000709
DE
207R00000X
Internal Medicine Physician
MD043019E
PA
2083X0100X
Occupational Medicine Physician
Primary
MD043019E
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1000030188
—
DE
01
—
C1-0000709
PROFESSIONAL LICENSE
DE
01
—
MD043019E
LICENSE
PA
Enumeration date
01/23/2007
Last updated
12/05/2016
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