Provider Demographics
NPI:1083785513
Name:GILLILAND, THERESA LYNN (NP-C FNP PMHNP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LYNN
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:NP-C FNP PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 BIG ROCK LN
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:CO
Mailing Address - Zip Code:80421-1800
Mailing Address - Country:US
Mailing Address - Phone:530-409-1659
Mailing Address - Fax:
Practice Address - Street 1:1600 SAN PEDRO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6734
Practice Address - Country:US
Practice Address - Phone:505-404-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995151-NP363LP0808X
NMCNP-01630363L00000X
CA11076363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP10249Medicare UPIN