Provider Demographics
NPI:1053626309
Name:ULLOM, ANDREW DAVID (STNA)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:DAVID
Last Name:ULLOM
Suffix:
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:OH
Mailing Address - Zip Code:43821-9653
Mailing Address - Country:US
Mailing Address - Phone:740-221-0678
Mailing Address - Fax:
Practice Address - Street 1:31 W 11TH ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:OH
Practice Address - Zip Code:43821-9653
Practice Address - Country:US
Practice Address - Phone:740-221-0678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400444950105376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide