Healthcare Provider Details

I. General information

NPI: 1033489943
Provider Name (Legal Business Name): BROOK PAYNE NOWAK APRN, MSN, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-2676
  • Fax:
Mailing address:
  • Phone: 919-784-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number16392
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number5009709
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: