Healthcare Provider Details

I. General information

NPI: 1467075663
Provider Name (Legal Business Name): PROACTIVE NUTRITION & WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 PALM BREEZE DR
EDGEWATER FL
32141-5901
US

IV. Provider business mailing address

114 PALM BREEZE DR
EDGEWATER FL
32141-5901
US

V. Phone/Fax

Practice location:
  • Phone: 727-409-0016
  • Fax:
Mailing address:
  • Phone: 727-409-0016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW WINQUIST
Title or Position: PRESIDENT
Credential: RD/LDN
Phone: 727-409-0016