Healthcare Provider Details

I. General information

NPI: 1881361335
Provider Name (Legal Business Name): INNOVATIVE ADVANCED PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 HEALTHWAY DR STE 140
AURORA IL
60504-8184
US

IV. Provider business mailing address

4050 HEALTHWAY DR STE 140
AURORA IL
60504-8184
US

V. Phone/Fax

Practice location:
  • Phone: 630-549-5429
  • Fax: 773-912-6727
Mailing address:
  • Phone: 630-549-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDNESHA RAMEY
Title or Position: CO-OWNER/NURSE PRACTITIONER
Credential: NP
Phone: 630-549-5429