Provider Demographics
NPI:1861622722
Name:INNOVATIVE HEALTHCARE MANAGEMENT LLC
Entity type:Organization
Organization Name:INNOVATIVE HEALTHCARE MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:DRYER
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:480-478-0520
Mailing Address - Street 1:PO BOX 2049
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-2049
Mailing Address - Country:US
Mailing Address - Phone:480-478-0520
Mailing Address - Fax:480-478-0633
Practice Address - Street 1:3078 HIGHWAY 98 E
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-8267
Practice Address - Country:US
Practice Address - Phone:601-205-9994
Practice Address - Fax:480-478-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-24
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ320915Medicaid
AZZ131830OtherMEDICARE PTAN