Provider Demographics
NPI:1467252098
Name:PETERSON, ALEXIS NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:PETERSON
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E MAIN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3857
Mailing Address - Country:US
Mailing Address - Phone:701-319-0402
Mailing Address - Fax:
Practice Address - Street 1:200 E MAIN AVE STE 101
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3857
Practice Address - Country:US
Practice Address - Phone:701-319-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND22234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist