Healthcare Provider Details

I. General information

NPI: 1265916662
Provider Name (Legal Business Name): MISTY NOVAKOWSKI REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 N MILL ST
PLYMOUTH MI
48170-1425
US

IV. Provider business mailing address

981 N MILL ST
PLYMOUTH MI
48170-1425
US

V. Phone/Fax

Practice location:
  • Phone: 734-624-2312
  • Fax:
Mailing address:
  • Phone: 810-991-1630
  • Fax: 810-991-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number4704290684
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: