Healthcare Provider Details

I. General information

NPI: 1952737124
Provider Name (Legal Business Name): PATHWAY TO WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5839 PEAR ORCHARD RD
JACKSON MS
39211-3311
US

IV. Provider business mailing address

5839 PEAR ORCHARD RD
JACKSON MS
39211-3311
US

V. Phone/Fax

Practice location:
  • Phone: 769-572-4286
  • Fax:
Mailing address:
  • Phone: 769-572-4286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12329
License Number StateMS
# 5
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. GETTY E ISRAEL
Title or Position: EXECUTIVE DIRECTOR
Credential: M.PH
Phone: 769-572-4286