Provider Demographics
NPI:1598446437
Name:NICOLDS, KYRIE JAE (PA-S)
Entity Type:Individual
Prefix:
First Name:KYRIE
Middle Name:JAE
Last Name:NICOLDS
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:KYRIE
Other - Middle Name:JAE
Other - Last Name:SUTHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1616 SPRING VALLEY DR APT 20
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-9435
Mailing Address - Country:US
Mailing Address - Phone:801-564-4186
Mailing Address - Fax:
Practice Address - Street 1:1542 SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9501
Practice Address - Country:US
Practice Address - Phone:304-696-6035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant