Healthcare Provider Details

I. General information

NPI: 1992324149
Provider Name (Legal Business Name): WELL LIFE ABQ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 OSUNA RD NE STE 5C
ALBUQUERQUE NM
87111-2072
US

IV. Provider business mailing address

5901J WYOMING BLVD NE # 351
ALBUQUERQUE NM
87109-3866
US

V. Phone/Fax

Practice location:
  • Phone: 505-585-2345
  • Fax: 505-800-5030
Mailing address:
  • Phone: 505-585-2345
  • Fax: 505-800-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE DEVINE
Title or Position: OWNER
Credential: APRN
Phone: 505-585-2345