Healthcare Provider Details

I. General information

NPI: 1922478593
Provider Name (Legal Business Name): NICOLE ANNE KANDRA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 NEELY RD
FORT WAINWRIGHT AK
99703
US

IV. Provider business mailing address

5623 MASON LN
KLAMATH FALLS OR
97601-9379
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-5172
  • Fax:
Mailing address:
  • Phone: 541-591-4719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-10197732
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number251
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA160804654
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number251410
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: