Healthcare Provider Details

I. General information

NPI: 1164366134
Provider Name (Legal Business Name): AGATHA CHINYERE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 S BROADWAY STE 500
MINOT ND
58701-6508
US

IV. Provider business mailing address

1940 S BROADWAY STE 500
MINOT ND
58701-6508
US

V. Phone/Fax

Practice location:
  • Phone: 701-389-4164
  • Fax:
Mailing address:
  • Phone: 701-389-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number203969
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: