NPIMap

Organization Active NPI

Proactive Wellnessnp

  • Multi-Specialty Clinic/Center
  • Columbia, MD
National Provider Identifier
1124704085
Registry record updated Dec 6, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
PROACTIVE WELLNESSNP
Practice address
12114 Blue Flag Way
Columbia, MD 21044
Phone
(301) 741-0307
NPI assigned
Jun 26, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 6, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kondi Walterssmith, CRNPNPI 1780190595
Title
Ceo/ Nurse Practitioner
Phone
(301) 741-0307

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X Primary
Recovery Care Clinic/Center 261QR0800X

Addresses

Primary practice location

12114 Blue Flag Way
Columbia, MD 21044

Mailing address

12114 Blue Flag Way
Columbia, MD 21044
Phone (301) 741-0307

Other names 1

  • Proactive Wellness NP Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1687737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701820800000",
    "number": "1124704085",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12114 BLUE FLAG WAY",
            "city": "COLUMBIA",
            "state": "MD",
            "postal_code": "21044",
            "telephone_number": "301-741-0307"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12114 BLUE FLAG WAY",
            "city": "COLUMBIA",
            "state": "MD",
            "postal_code": "21044",
            "telephone_number": "301-741-0307"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROACTIVE WELLNESSNP",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-06-26",
        "last_updated": "2023-12-06",
        "certification_date": "2023-12-06",
        "status": "A",
        "authorized_official_last_name": "WALTERSSMITH",
        "authorized_official_first_name": "KONDI",
        "authorized_official_title_or_position": "CEO/ NURSE PRACTITIONER",
        "authorized_official_telephone_number": "301-741-0307",
        "authorized_official_credential": "CRNP"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR0800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Recovery Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Proactive Wellness NP",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Proactive Wellness NP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Columbia, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 6, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.