MEDICARE: MS. LYNI MARIE NOWAK FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704118575	MI

General Provider Information

NPI Number	:	1275519159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LYNI MARIE NOWAK FNP

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE # MC845
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4499 220TH AVE
Second Line	:
City	:	REED CITY
State	:	MI
Zip	:	49677-8593
Country	:	US
Telephone Number	:	231-832-5817
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	11/22/2017

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