Healthcare Provider Details

I. General information

NPI: 1912040288
Provider Name (Legal Business Name): TERESA DIANE PRATT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CERRILLOS RD
SANTA FE NM
87505-3554
US

IV. Provider business mailing address

1700 CERRILLOS RD
SANTA FE NM
87505-3026
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-9821
  • Fax: 505-983-6243
Mailing address:
  • Phone: 505-946-9361
  • Fax: 505-946-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD24281
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number29045
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: