Healthcare Provider Details

I. General information

NPI: 1629575261
Provider Name (Legal Business Name): LINDSEY MAE NOVACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S 41ST ST
MANITOWOC WI
54220-7316
US

IV. Provider business mailing address

1650 S 41ST ST
MANITOWOC WI
54220-7316
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-2436
  • Fax:
Mailing address:
  • Phone: 920-320-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number235214
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13710-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: