Healthcare Provider Details

I. General information

NPI: 1205763778
Provider Name (Legal Business Name): SHANNON NOVAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 BROAD ST STE 3
RED BANK NJ
07701-2036
US

IV. Provider business mailing address

9 BRIDGEWATERS DR APT 23
OCEANPORT NJ
07757-1159
US

V. Phone/Fax

Practice location:
  • Phone: 732-982-6128
  • Fax: 732-383-8196
Mailing address:
  • Phone: 732-982-6128
  • Fax: 732-383-8196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11047425
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ155572200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: