Healthcare Provider Details

I. General information

NPI: 1467963942
Provider Name (Legal Business Name): INA VATE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 S HIGHWAY 95
FORT MOHAVE AZ
86426-9225
US

IV. Provider business mailing address

8612 RANCHO DR
OOLTEWAH TN
37363-9233
US

V. Phone/Fax

Practice location:
  • Phone: 928-788-7077
  • Fax: 469-249-1170
Mailing address:
  • Phone: 678-982-9343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN168442
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28976
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: