Provider Demographics
NPI:1104535335
Name:INNOVATIVE WOMEN'S HEALTHCARE, PLLC
Entity type:Organization
Organization Name:INNOVATIVE WOMEN'S HEALTHCARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, PMHNP-BC
Authorized Official - Phone:618-444-5475
Mailing Address - Street 1:1087 IL ROUTE 127
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-3041
Mailing Address - Country:US
Mailing Address - Phone:618-444-5475
Mailing Address - Fax:
Practice Address - Street 1:2016 VADALABENE DR STE D
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-6901
Practice Address - Country:US
Practice Address - Phone:618-444-5475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty