Healthcare Provider Details

I. General information

NPI: 1912802224
Provider Name (Legal Business Name): ANIKA SOFIE TOLLERUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 E MCARTHUR ST
APPLETON WI
54911-2118
US

IV. Provider business mailing address

512 E MCARTHUR ST
APPLETON WI
54911-2118
US

V. Phone/Fax

Practice location:
  • Phone: 920-903-4133
  • Fax:
Mailing address:
  • Phone: 920-903-4133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: