Healthcare Provider Details

I. General information

NPI: 1407730799
Provider Name (Legal Business Name): THYRA PETERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E STE 101
ALEXANDRIA MN
56308-5274
US

IV. Provider business mailing address

1670 137TH AVE NE
HATTON ND
58240-9014
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1144
  • Fax:
Mailing address:
  • Phone: 218-779-3188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3977
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: