Provider Demographics
NPI:1982381331
Name:ULTZ, JANELLE MARIE
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:MARIE
Last Name:ULTZ
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 1:65120 MIDDLE COLON RD
Mailing Address - Street 2:
Mailing Address - City:BURR OAK
Mailing Address - State:MI
Mailing Address - Zip Code:49030-9679
Mailing Address - Country:US
Mailing Address - Phone:269-503-4879
Mailing Address - Fax:
Practice Address - Street 1:31550 TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:BURR OAK
Practice Address - State:MI
Practice Address - Zip Code:49030-9799
Practice Address - Country:US
Practice Address - Phone:269-503-4879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS750396475251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health