Provider Demographics
NPI:1306506019
Name:OMEDDO, MARY TERESA (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:OMEDDO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:OMEDDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-0340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85 WEST HWY 22
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO
Practice Address - State:NM
Practice Address - Zip Code:87052
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX889413163WC1500X
NM65654163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health