Basic Information
| Provider Information | |||||||||
| NPI: | 1700152584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOLLY | ||||||||
| FirstName: | O. | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | MS FNP RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32430 US ROUTE 11 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136732162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156420405 | ||||||||
| FaxNumber: | 3156423180 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 COMMERCE LN | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136173739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868191 | ||||||||
| FaxNumber: | 3153861410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2012 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 337986 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 462795-1 | NY | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 251300000X | 01 | TAXONOMY CODE | OTHER |