Healthcare Provider Details

I. General information

NPI: 1306371158
Provider Name (Legal Business Name): JANELLE MARIE ULLRICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 4TH AVE SE SUITE 1
CEDAR RAPIDS IA
52403-2445
US

IV. Provider business mailing address

830 4TH AVE SE SUITE 1
CEDAR RAPIDS IA
52403-2445
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-8121
  • Fax: 319-365-1396
Mailing address:
  • Phone: 319-363-8121
  • Fax: 319-365-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number088327
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: