Healthcare Provider Details

I. General information

NPI: 1124547740
Provider Name (Legal Business Name): BREANNE LINDSAY NOVAK MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 S SCHODACK RD
CASTLETON NY
12033-9644
US

IV. Provider business mailing address

1477 S SCHODACK RD
CASTLETON NY
12033-9644
US

V. Phone/Fax

Practice location:
  • Phone: 518-477-7103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number759566131
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1231335181
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: