Provider Demographics
NPI:1811025703
Name:BUBENZER, THERESA ANN (FNP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
Last Name:BUBENZER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 WEST RD STE A
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2292
Mailing Address - Country:US
Mailing Address - Phone:505-661-8900
Mailing Address - Fax:505-661-8916
Practice Address - Street 1:3917 WEST RD STE A
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2292
Practice Address - Country:US
Practice Address - Phone:505-661-8900
Practice Address - Fax:505-661-8916
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002349A363LF0000X
NMRN-75785163W00000X
NMCNP-01998363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71002349AOtherNP LICENSE
NMCNP-01998OtherSTATE LICENSE