Provider Demographics
NPI:1689115818
Name:ULLENBERG, MOLLY MARIE (AGPCNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:MOLLY
Middle Name:MARIE
Last Name:ULLENBERG
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16655 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5957
Mailing Address - Country:US
Mailing Address - Phone:414-257-1708
Mailing Address - Fax:414-257-1787
Practice Address - Street 1:16655 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5957
Practice Address - Country:US
Practice Address - Phone:414-257-1708
Practice Address - Fax:414-257-1787
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7448363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care