Healthcare Provider Details

I. General information

NPI: 1538167077
Provider Name (Legal Business Name): GRETCHEN L TOLSMA APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2327 NEVA RD
ANTIGO WI
54409-2912
US

IV. Provider business mailing address

2327 NEVA RD
ANTIGO WI
54409-2912
US

V. Phone/Fax

Practice location:
  • Phone: 715-623-2123
  • Fax: 715-623-6556
Mailing address:
  • Phone: 715-623-2123
  • Fax: 715-623-6556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1399
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1399-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: