Provider Demographics
NPI:1710370838
Name:POTOMAC WELLNESS
Entity Type:Organization
Organization Name:POTOMAC WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WIELAND
Authorized Official - Suffix:
Authorized Official - Credentials:RD, RN, CDE
Authorized Official - Phone:571-348-4451
Mailing Address - Street 1:46494 PRIMULA CT
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-7248
Mailing Address - Country:US
Mailing Address - Phone:571-348-4451
Mailing Address - Fax:
Practice Address - Street 1:46494 PRIMULA CT
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-7248
Practice Address - Country:US
Practice Address - Phone:571-348-4451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
708956133V00000X
VA0001149354163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty