Healthcare Provider Details

I. General information

NPI: 1801316740
Provider Name (Legal Business Name): TERRY WATERS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 INDUSTRIAL PARK RD
ESPANOLA NM
87532-3600
US

IV. Provider business mailing address

2010 INDUSTRIAL PARK RD
ESPANOLA NM
87532-3600
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7395
  • Fax: 505-753-8373
Mailing address:
  • Phone: 505-927-7912
  • Fax: 505-753-5522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03263
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: