Provider Demographics
NPI:1306371158
Name:ULLRICH, JANELLE MARIE
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:MARIE
Last Name:ULLRICH
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 1:830 4TH AVE SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2445
Mailing Address - Country:US
Mailing Address - Phone:319-363-8121
Mailing Address - Fax:319-365-1396
Practice Address - Street 1:830 4TH AVE SE
Practice Address - Street 2:SUITE 1
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2445
Practice Address - Country:US
Practice Address - Phone:319-363-8121
Practice Address - Fax:319-365-1396
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA088327363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program