Provider Demographics
NPI:1174830947
Name:ULMER, MARY BETH (CST)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:ULMER
Suffix:
Gender:F
Credentials:CST
Other - Prefix:MRS
Other - First Name:MARYBETH
Other - Middle Name:
Other - Last Name:ULMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CST
Mailing Address - Street 1:PO BOX 95004
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-5004
Mailing Address - Country:US
Mailing Address - Phone:863-680-7206
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1755 N. FLORIDA AVENUE
Practice Address - Street 2:BELLA VISTA BLDG.
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3109
Practice Address - Country:US
Practice Address - Phone:863-904-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL#119593246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist