Provider Demographics
NPI:1942719133
Name:ULMER, TRACEY ANN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
Last Name:ULMER
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 1:622 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2329
Mailing Address - Country:US
Mailing Address - Phone:517-548-0081
Mailing Address - Fax:
Practice Address - Street 1:622 GRAND RIVER
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843
Practice Address - Country:US
Practice Address - Phone:517-548-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
MI175T00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI047Medicaid