Healthcare Provider Details

I. General information

NPI: 1164746475
Provider Name (Legal Business Name): TRICIA LEIGH TOLLENAAR CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MAGNETIC ST ANESTHESIA DEPT.
MARQUETTE MI
49855-2711
US

IV. Provider business mailing address

351 W MAIN ST UNIT # 9
MARQUETTE MI
49855-9348
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3595
  • Fax:
Mailing address:
  • Phone: 239-580-7379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704235224
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: