1265040380 NPI number — PATHWAY TO WELLNESS HEALTHCARE CENTER

Table of content: (NPI 1265040380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265040380 NPI number — PATHWAY TO WELLNESS HEALTHCARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHWAY TO WELLNESS HEALTHCARE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265040380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 N CHARLES ST STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21201-5594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-739-3814
Provider Business Mailing Address Fax Number:
833-975-0904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 EDMONDSON AVE STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21229-1614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-739-3814
Provider Business Practice Location Address Fax Number:
240-348-2962
Provider Enumeration Date:
07/14/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HICKSON
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
443-739-3814

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 666351600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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