Provider Demographics
NPI:1639515968
Name:ULICNY, JENNIFER LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ULICNY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 CLOUD COVER LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-6603
Mailing Address - Country:US
Mailing Address - Phone:603-320-5984
Mailing Address - Fax:
Practice Address - Street 1:1342 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4436
Practice Address - Country:US
Practice Address - Phone:603-320-5984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN229427367500000X
NC263035367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered