Healthcare Provider Details

I. General information

NPI: 1134155773
Provider Name (Legal Business Name): THERESA JEAN ULICHNEY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESA CADA

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 POLIFKA DR
SHAW AFB SC
29152
US

IV. Provider business mailing address

420 POLIFKA DR
SHAW AFB SC
29152-5100
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-6812
  • Fax: 803-895-6030
Mailing address:
  • Phone: 803-895-6812
  • Fax: 803-895-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberA18512
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP30007901
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number00175079
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: