Provider Demographics
NPI:1841714300
Name:TEDDER, BRANDI LYNNETTE (FNP-C)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:LYNNETTE
Last Name:TEDDER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:LYNNETTE
Other - Last Name:VILLARREAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1600 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:575-396-5640
Practice Address - Street 1:1600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-5640
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134377363L00000X
NMCNP-03427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66806569Medicaid