Provider Demographics
NPI:1043890619
Name:TOLLERUD, MICHELLE ANN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:TOLLERUD
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 1:123 ALTA AVE N
Mailing Address - Street 2:
Mailing Address - City:ESMOND
Mailing Address - State:ND
Mailing Address - Zip Code:58332-3203
Mailing Address - Country:US
Mailing Address - Phone:701-351-2297
Mailing Address - Fax:
Practice Address - Street 1:123 ALTA AVE N
Practice Address - Street 2:
Practice Address - City:ESMOND
Practice Address - State:ND
Practice Address - Zip Code:58332-3203
Practice Address - Country:US
Practice Address - Phone:701-351-2297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant