Provider Demographics
NPI:1386026078
Name:ULLERY, CANDICE (SBD)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:ULLERY
Suffix:
Gender:F
Credentials:SBD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 OGLESBY ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2725
Mailing Address - Country:US
Mailing Address - Phone:618-292-8518
Mailing Address - Fax:
Practice Address - Street 1:416 OGLESBY ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2725
Practice Address - Country:US
Practice Address - Phone:618-292-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSBD20110800374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOSBD20110800OtherSTILLBIRTHDAY