Healthcare Provider Details

I. General information

NPI: 1831941970
Provider Name (Legal Business Name): TWIN PORTS TELEMEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 AUNE RD
SAGINAW MN
55779-9682
US

IV. Provider business mailing address

4727 AUNE RD
SAGINAW MN
55779-9682
US

V. Phone/Fax

Practice location:
  • Phone: 218-391-6264
  • Fax:
Mailing address:
  • Phone: 218-391-6264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NICOLE SHOCKLEY
Title or Position: OWNER
Credential: APRN
Phone: 888-820-1235