Healthcare Provider Details

I. General information

NPI: 1477920841
Provider Name (Legal Business Name): SUSAN C NOVAK-NIZAMI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BALFOUR RD. PATIENT SUPPORT SERVICES
BRENTWOOD CA
94513
US

IV. Provider business mailing address

2400 BALFOUR RD. PATIENT SUPPORT SERVICES
BRENTWOOD CA
94513
US

V. Phone/Fax

Practice location:
  • Phone: 925-308-8170
  • Fax:
Mailing address:
  • Phone: 925-308-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95004895
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number644241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: