Healthcare Provider Details

I. General information

NPI: 1053922559
Provider Name (Legal Business Name): ALINE NOELLE ULLOA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

6004 AKIN SONG
SAN ANTONIO TX
78261-2175
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-2798
  • Fax:
Mailing address:
  • Phone: 253-310-6980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number1023292
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: