Basic Information
| Provider Information | |||||||||
| NPI: | 1790955409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ULRICH | ||||||||
| FirstName: | NINA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | WHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUCKER | ||||||||
| OtherFirstName: | NINA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN MS COGNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9520 W PALM LN | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850374403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235568860 | ||||||||
| FaxNumber: | 6238769559 | ||||||||
| Practice Location | |||||||||
| Address1: | 15351 W. BELL RD. | ||||||||
| Address2: | |||||||||
| City: | SUPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
| FaxNumber: | 8778095092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | RN062482 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 197352 | 05 | AZ | MEDICAID |