Provider Demographics
NPI:1841565801
Name:WELL PATH, LLC.
Entity type:Organization
Organization Name:WELL PATH, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APN
Authorized Official - Phone:856-432-6257
Mailing Address - Street 1:110 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-1634
Mailing Address - Country:US
Mailing Address - Phone:856-432-6257
Mailing Address - Fax:856-432-1526
Practice Address - Street 1:110 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1634
Practice Address - Country:US
Practice Address - Phone:856-432-6257
Practice Address - Fax:856-432-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00012600364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty