Provider Demographics
NPI:1093032484
Name:ULRICH, NICOLE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:ULRICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:CHARBONEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4670 PARK NICOLLET AVE SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-4119
Mailing Address - Country:US
Mailing Address - Phone:952-993-8829
Mailing Address - Fax:
Practice Address - Street 1:4670 PARK NICOLLET AVE SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-4119
Practice Address - Country:US
Practice Address - Phone:952-993-8829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN54301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program