Basic Information
| Provider Information | |||||||||
| NPI: | 1679231443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOLLEY | ||||||||
| FirstName: | BRAYDEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2021 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP61241173 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.