Healthcare Provider Details

I. General information

NPI: 1689552275
Provider Name (Legal Business Name): TERESITA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 5TH ST STE 100
SANTA FE NM
87505-5403
US

IV. Provider business mailing address

PO BOX 8124
SANTA FE NM
87504-8124
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-9276
  • Fax:
Mailing address:
  • Phone: 505-946-7405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: