Provider Demographics
NPI:1881361335
Name:INNOVATIVE ADVANCED PRACTICE LLC
Entity type:Organization
Organization Name:INNOVATIVE ADVANCED PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:EDNESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMEY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:630-549-5429
Mailing Address - Street 1:4050 HEALTHWAY DR STE 140
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-8184
Mailing Address - Country:US
Mailing Address - Phone:630-549-5429
Mailing Address - Fax:
Practice Address - Street 1:4050 HEALTHWAY DR STE 140
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-8184
Practice Address - Country:US
Practice Address - Phone:630-549-5429
Practice Address - Fax:773-912-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1609354133Medicaid