Healthcare Provider Details

I. General information

NPI: 1205935004
Provider Name (Legal Business Name): TERESE AILEEN O'NEIL SELVAGE MN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESE AILEEN O'NEIL MN, CNP

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 CAMINO DE CRUZ BLANCA
SANTA FE NM
87505-4584
US

IV. Provider business mailing address

PO BOX 6880
SANTA FE NM
87502-6880
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-6418
  • Fax: 505-984-6918
Mailing address:
  • Phone: 505-216-0332
  • Fax: 505-982-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00790
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR36675
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: