Healthcare Provider Details

I. General information

NPI: 1801362231
Provider Name (Legal Business Name): INNOVA DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MAPLE ROW BLVD
HENDERSONVILLE TN
37075-3853
US

IV. Provider business mailing address

105 MAPLE ROW BLVD
HENDERSONVILLE TN
37075-3853
US

V. Phone/Fax

Practice location:
  • Phone: 615-266-3376
  • Fax: 484-918-8506
Mailing address:
  • Phone: 615-266-3376
  • Fax: 484-918-8506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARGARET WING-YAN MANN
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 615-266-3376