Provider Demographics
NPI:1174722888
Name:JOLLIFFE, SCOTT ALLAN (CRNA)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALLAN
Last Name:JOLLIFFE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 N RUSTY NAIL RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1478
Mailing Address - Country:US
Mailing Address - Phone:503-277-0265
Mailing Address - Fax:
Practice Address - Street 1:5430 DISTINCTION WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-8437
Practice Address - Country:US
Practice Address - Phone:928-445-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200960029CRNA367500000X
AZCRNA1473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO917333007Medicaid
MO917333007Medicaid
835660042Medicare PIN
IL$$$$$$$$$001Medicaid
OTH000Medicare UPIN