Provider Demographics
NPI:1790842383
Name:PROACTIVE NUTRITION & FITNESS, INC
Entity Type:Organization
Organization Name:PROACTIVE NUTRITION & FITNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RD,LD N
Authorized Official - Phone:352-258-8220
Mailing Address - Street 1:2106 SW 39TH DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-4346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2106 SW 39TH DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4346
Practice Address - Country:US
Practice Address - Phone:352-258-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4570133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty