Provider Demographics
NPI:1124704085
Name:PROACTIVE WELLNESSNP
Entity type:Organization
Organization Name:PROACTIVE WELLNESSNP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/ NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KONDI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERSSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:301-741-0307
Mailing Address - Street 1:12114 BLUE FLAG WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044
Mailing Address - Country:US
Mailing Address - Phone:301-741-0307
Mailing Address - Fax:
Practice Address - Street 1:12114 BLUE FLAG WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044
Practice Address - Country:US
Practice Address - Phone:301-741-0307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care