Healthcare Provider Details

I. General information

NPI: 1912815077
Provider Name (Legal Business Name): EVELYN ROSE NOWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3767 DELAWARE AVE
KENMORE NY
14217-1040
US

IV. Provider business mailing address

27 FALCONCREST LN
ORCHARD PARK NY
14127-1673
US

V. Phone/Fax

Practice location:
  • Phone: 716-874-6175
  • Fax:
Mailing address:
  • Phone: 716-874-6175
  • Fax: 716-874-6175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number056264
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: