Provider Demographics
NPI:1205935004
Name:SELVAGE, TERESE AILEEN O'NEIL (MN, CNP)
Entity type:Individual
Prefix:
First Name:TERESE
Middle Name:AILEEN O'NEIL
Last Name:SELVAGE
Suffix:
Gender:F
Credentials:MN, CNP
Other - Prefix:
Other - First Name:TERESE
Other - Middle Name:AILEEN
Other - Last Name:O'NEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MN, CNP
Mailing Address - Street 1:PO BOX 6880
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6880
Mailing Address - Country:US
Mailing Address - Phone:505-216-0332
Mailing Address - Fax:505-982-0279
Practice Address - Street 1:1160 CAMINO DE CRUZ BLANCA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4584
Practice Address - Country:US
Practice Address - Phone:505-984-6418
Practice Address - Fax:505-984-6918
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00790363LF0000X
NMR36675363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily