Healthcare Provider Details

I. General information

NPI: 1205769684
Provider Name (Legal Business Name): KYRA NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 23RD AVE S
FARGO ND
58104-7927
US

IV. Provider business mailing address

3155 49TH ST S APT 313
FARGO ND
58104-4536
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-2000
  • Fax:
Mailing address:
  • Phone: 507-259-2548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2893
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: