Healthcare Provider Details

I. General information

NPI: 1326378035
Provider Name (Legal Business Name): TINA NOWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BROAD ST
BREVARD NC
28712-4044
US

IV. Provider business mailing address

501 S BROAD ST
BREVARD NC
28712-4044
US

V. Phone/Fax

Practice location:
  • Phone: 828-278-0563
  • Fax: 828-884-2187
Mailing address:
  • Phone: 828-278-0563
  • Fax: 828-884-2187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number166540
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: