Provider Demographics
NPI:1730540741
Name:INNOVO LIFE, LLC
Entity type:Organization
Organization Name:INNOVO LIFE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-355-8587
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21150-0212
Mailing Address - Country:US
Mailing Address - Phone:202-355-8587
Mailing Address - Fax:
Practice Address - Street 1:8101 SANDY SPRING RD STE 250
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3527
Practice Address - Country:US
Practice Address - Phone:202-355-8587
Practice Address - Fax:202-478-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty