Provider Demographics
NPI:1427336825
Name:LULLMAN, NICOLE DIANN
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:DIANN
Last Name:LULLMAN
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 1:1409 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1964
Mailing Address - Country:US
Mailing Address - Phone:515-643-6554
Mailing Address - Fax:515-643-6555
Practice Address - Street 1:1409 CLARK ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1964
Practice Address - Country:US
Practice Address - Phone:515-643-6554
Practice Address - Fax:515-643-6555
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08116101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor