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General NPI Number Information
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NPI Number | 1124756002
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Entity Type | Individual
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Provider Name | MRS. JILL MARIE ULLMER
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Gender | Female
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Dates
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Enumeration Date | 08/09/2022
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Last Update Date | 08/09/2022
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Provider Practice Location Address
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Address Line | 801 HOFFMAN RD STE 106
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City | GREEN BAY
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State | WI
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Zip | 54301-1462
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Country | US
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Telephone | 920-277-6989
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Fax |
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Provider Business Mailing Address
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Address Line | N5972 VINE RD
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City | SEYMOUR
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State | WI
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Zip | 54165-8148
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Country | US
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Telephone | 920-277-6989
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 717-403
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License Number State | WI
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