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General NPI Number Information
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NPI Number | 1669158929
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Entity Type | Organization
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Legal Business Name | INNOVATIVE HEALTHY AGING, LLC
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Dates
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Enumeration Date | 06/22/2023
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Last Update Date | 03/20/2024
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Provider Practice Location Address
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Address Line | 1120 PINELLAS BAYWAY S STE 105
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City | TIERRA VERDE
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State | FL
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Zip | 33715-1500
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Country | US
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Telephone | 727-282-9724
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Fax | 727-317-0043
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Provider Business Mailing Address
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Address Line | 841 2ND AVE S
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City | TIERRA VERDE
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State | FL
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Zip | 33715-2249
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Country | US
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Telephone | 407-421-6600
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Fax | 727-317-0043
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Authorized Official
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Title or Position | NURSE PRACTIONER
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Name | TERESA ANNETTE NESBIT
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Credential | CNM, APRN
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Telephone | 727-282-9724
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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