Healthcare Provider Details

I. General information

NPI: 1568394443
Provider Name (Legal Business Name): KYRA JAE GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 S LOUISE AVE
SIOUX FALLS SD
57108-6021
US

IV. Provider business mailing address

511 E 4TH ST 1/2
DELL RAPIDS SD
57022-2009
US

V. Phone/Fax

Practice location:
  • Phone: 605-504-1100
  • Fax:
Mailing address:
  • Phone: 605-261-0576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000060204
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: