Healthcare Provider Details

I. General information

NPI: 1053740415
Provider Name (Legal Business Name): MAUREEN NOWACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 2ND ST NE
MINNEAPOLIS MN
55418-4306
US

IV. Provider business mailing address

14850 UNIVERSITY AVE NW
ANDOVER MN
55304-6023
US

V. Phone/Fax

Practice location:
  • Phone: 612-706-5533
  • Fax: 612-706-5509
Mailing address:
  • Phone: 763-228-2470
  • Fax: 763-438-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR129516-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: