Healthcare Provider Details

I. General information

NPI: 1023346798
Provider Name (Legal Business Name): ELIZABETH THERKILSEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BASS LAKE RD
NEW HOPE MN
55428-3105
US

IV. Provider business mailing address

PO BOX 772 MINUTECLINIC CREDENTIALING, ATTN: KRISTY OLIVER
WOONSOCKET RI
02895-0784
US

V. Phone/Fax

Practice location:
  • Phone: 763-257-0130
  • Fax:
Mailing address:
  • Phone: 401-770-1707
  • Fax: 401-652-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR 111685-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: