Healthcare Provider Details

I. General information

NPI: 1003371782
Provider Name (Legal Business Name): KYRIE MARIE SEVERSON APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4622 40TH AVE S SUITE A
FARGO ND
58104
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-2909
  • Fax: 701-364-9822
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR37913
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: