Healthcare Provider Details

I. General information

NPI: 1063369650
Provider Name (Legal Business Name): THERESA BAILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 W ARRINGTON ST
FARMINGTON NM
87401-8513
US

IV. Provider business mailing address

653 W ARRINGTON ST
FARMINGTON NM
87401-8513
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-3733
  • Fax: 505-324-1051
Mailing address:
  • Phone: 505-564-3733
  • Fax: 505-324-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2072
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2272026
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: