Healthcare Provider Details

I. General information

NPI: 1417821471
Provider Name (Legal Business Name): DR. DAVINA KAY AIKO DIETRICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 45TH ST S
FARGO ND
58103-1189
US

IV. Provider business mailing address

1914 13TH AVE N
MOORHEAD MN
56560-1820
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax:
Mailing address:
  • Phone: 701-239-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001312271
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: