Healthcare Provider Details

I. General information

NPI: 1659733731
Provider Name (Legal Business Name): TERA GARDNER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERA GERICKE APRN

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 HIGH RESORT BLVD SE
RIO RANCHO NM
87124-5906
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-6000
  • Fax: 505-727-9590
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016009388
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-77233-122
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number54686
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: