Healthcare Provider Details

I. General information

NPI: 1861622722
Provider Name (Legal Business Name): INNOVATIVE HEALTHCARE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3078 HIGHWAY 98 E
MCCOMB MS
39648-8267
US

IV. Provider business mailing address

PO BOX 2049
MCCOMB MS
39649-2049
US

V. Phone/Fax

Practice location:
  • Phone: 601-205-9994
  • Fax: 480-478-0633
Mailing address:
  • Phone: 480-478-0520
  • Fax: 480-478-0633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATRINA MARIA DRYER
Title or Position: NURSE PRACTITIONER
Credential: CFNP
Phone: 480-478-0520