Healthcare Provider Details

I. General information

NPI: 1003385048
Provider Name (Legal Business Name): KATHLEEN NOVAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10725 OLD POND DR
MONTGOMERY OH
45249-3532
US

IV. Provider business mailing address

11101 ALLENHURST BLVD E
CINCINNATI OH
45241-6619
US

V. Phone/Fax

Practice location:
  • Phone: 513-520-9639
  • Fax:
Mailing address:
  • Phone: 513-252-3853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN.328998
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: