Provider Demographics
NPI:1669158929
Name:INNOVATIVE HEALTHY AGING, LLC
Entity type:Organization
Organization Name:INNOVATIVE HEALTHY AGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:NESBIT
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, APRN
Authorized Official - Phone:727-282-9724
Mailing Address - Street 1:841 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-2249
Mailing Address - Country:US
Mailing Address - Phone:407-421-6600
Mailing Address - Fax:727-317-0043
Practice Address - Street 1:1120 PINELLAS BAYWAY S STE 105
Practice Address - Street 2:
Practice Address - City:TIERRA VERDE
Practice Address - State:FL
Practice Address - Zip Code:33715-1500
Practice Address - Country:US
Practice Address - Phone:727-282-9724
Practice Address - Fax:727-317-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-22
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center