Healthcare Provider Details

I. General information

NPI: 1528997632
Provider Name (Legal Business Name): DANIELLE NOVACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 EDMUND AVE
SAINT PAUL MN
55103-1608
US

IV. Provider business mailing address

451 EDMUND AVE
SAINT PAUL MN
55103-1608
US

V. Phone/Fax

Practice location:
  • Phone: 507-330-3913
  • Fax:
Mailing address:
  • Phone: 507-330-3913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1004636
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: