Provider Demographics
NPI:1205479417
Name:ULLOA, ESMERALDA ANTONIA
Entity type:Individual
Prefix:
First Name:ESMERALDA
Middle Name:ANTONIA
Last Name:ULLOA
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 1:76 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3810
Mailing Address - Country:US
Mailing Address - Phone:207-939-8490
Mailing Address - Fax:
Practice Address - Street 1:66 BRAMHALL ST STE G1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3344
Practice Address - Country:US
Practice Address - Phone:207-662-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP191274363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health