Healthcare Provider Details

I. General information

NPI: 1881480655
Provider Name (Legal Business Name): TERESA DEVEREAUX BERTONE REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 04/17/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1199
SHIPROCK NM
87420-1199
US

IV. Provider business mailing address

PO BOX 1199
SHIPROCK NM
87420-1199
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-5163
  • Fax: 505-368-5502
Mailing address:
  • Phone: 505-368-5163
  • Fax: 505-368-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number77574
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: