NPIMap

Individual provider Active NPI

Nicole Shockley, CNP

  • Nurse Practitioner
  • Duluth, MN
National Provider Identifier
1124569041
Registry record updated Jan 30, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
License
4971 Issued in MN
Practice address
4325 Grand Ave
Duluth, MN 55807-2730
Phone
(218) 722-1497
Fax
(218) 722-6239
NPI assigned
Mar 10, 2017
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 30, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Registered Nurse 163W00000X 1745474 MN
Registered Nurse 163W00000X 241302 WI
Nurse Practitioner 363L00000X 10568 WI
Nurse Practitioner 363L00000X 4971 MN Primary

Addresses

Primary practice location

4325 Grand Ave
Duluth, MN 55807-2730

Mailing address

2222 E 5TH St
Superior, WI 54880-3709
Phone (715) 392-1955

Other practice location 1

2222 E 5th St
Superior, WI 54880-3709
Phone (715) 392-1955

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20170324000042 MN Practitioner - Nurse Practitioner 5597040071 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2016
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services

Practice addresses (Care Compare)

Saginaw, MN 55779
Phone (888) 820-1235

Hospital & facility affiliations

  • St Lukes Hospital Hospital, Duluth, MN, CCN 240047

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Certified Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
1745474MNMDRegistered Nurse

Practice roles

OrganizationSpecialtyStatusNew patients
Twin Ports Telemedicine LLC CurrentSince Mar 1, 2024 Accepting new patients

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 26

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1489104000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1706572800000",
    "number": "1124569041",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2222 E 5TH ST",
            "city": "SUPERIOR",
            "state": "WI",
            "postal_code": "548803709",
            "telephone_number": "715-392-1955",
            "fax_number": "715-392-1935"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4325 GRAND AVE",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558072730",
            "telephone_number": "218-722-1497",
            "fax_number": "218-722-6239"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2222 E 5th St",
            "address_purpose": "LOCATION",
            "city": "Superior",
            "state": "WI",
            "postal_code": "548803709",
            "country_code": "US",
            "telephone_number": "715-392-1955",
            "fax_number": "715-394-2682",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SHOCKLEY",
        "first_name": "NICOLE",
        "credential": "CNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-03-10",
        "last_updated": "2024-01-30",
        "certification_date": "2024-01-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "MN",
            "license": "1745474",
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "WI",
            "license": "241302",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "WI",
            "license": "10568",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "MN",
            "license": "4971",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Duluth, MN

Sources for this page

Verify at the official NPI Registry.