Healthcare Provider Details

I. General information

NPI: 1689561136
Provider Name (Legal Business Name): SARAH GRACE NOVAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 ENTERPRISE CT STE C
BLOOMFIELD MI
48302-1055
US

IV. Provider business mailing address

4251 NELSEY RD
WATERFORD MI
48329-1055
US

V. Phone/Fax

Practice location:
  • Phone: 248-220-7505
  • Fax:
Mailing address:
  • Phone: 586-405-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number4704357625
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: