Healthcare Provider Details

I. General information

NPI: 1205433687
Provider Name (Legal Business Name): MALISE ANN NOVOTNY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9776 BONITA BEACH RD SE STE 201A
BONITA SPRINGS FL
34135-4775
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 239-947-3092
  • Fax: 239-947-5298
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11009559
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: