Provider Demographics
NPI:1992324149
Name:WELL LIFE ABQ, LLC
Entity type:Organization
Organization Name:WELL LIFE ABQ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:505-585-2345
Mailing Address - Street 1:5901J WYOMING BLVD NE # 351
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3866
Mailing Address - Country:US
Mailing Address - Phone:505-585-2345
Mailing Address - Fax:505-800-5030
Practice Address - Street 1:8400 OSUNA RD NE STE 5C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2072
Practice Address - Country:US
Practice Address - Phone:505-585-2345
Practice Address - Fax:505-800-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty