Provider Demographics
NPI:1215361605
Name:ULLOM, AMANDA CHANTEL
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CHANTEL
Last Name:ULLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2837
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-2837
Mailing Address - Country:US
Mailing Address - Phone:206-850-6692
Mailing Address - Fax:
Practice Address - Street 1:11801 NE 160TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-4106
Practice Address - Country:US
Practice Address - Phone:206-850-6692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00024803225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist