Provider Demographics
NPI:1407730799
Name:PETERICK, THYRA
Entity type:Individual
Prefix:
First Name:THYRA
Middle Name:
Last Name:PETERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 137TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HATTON
Mailing Address - State:ND
Mailing Address - Zip Code:58240-9014
Mailing Address - Country:US
Mailing Address - Phone:218-779-3188
Mailing Address - Fax:
Practice Address - Street 1:1301 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:218-779-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-01
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer