Healthcare Provider Details

I. General information

NPI: 1265602973
Provider Name (Legal Business Name): JANET ANNE NOVAK RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE KIRTLAND AIR FORCE BASE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

12010 STILWELL DR NE
ALBUQUERQUE NM
87112-3444
US

V. Phone/Fax

Practice location:
  • Phone: 505-974-1717
  • Fax:
Mailing address:
  • Phone: 505-974-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number376
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: