Provider Demographics
NPI:1619412004
Name:JOLLY, TINA (MSN, APRN, NP-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 317
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-0317
Mailing Address - Country:US
Mailing Address - Phone:478-864-3448
Mailing Address - Fax:478-864-1288
Practice Address - Street 1:107 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-272-3446
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1619412004Medicaid
TNQ071116Medicaid
GA003151473DMedicaid