Provider Demographics
NPI:1003282401
Name:NOVOTNY, ANGEL
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:NOVOTNY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANGEL
Other - Middle Name:D
Other - Last Name:NOVOTNY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2600 W BROADWAY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-6509
Mailing Address - Country:US
Mailing Address - Phone:580-622-2783
Mailing Address - Fax:580-622-5038
Practice Address - Street 1:127 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4700
Practice Address - Country:US
Practice Address - Phone:580-745-9535
Practice Address - Fax:580-745-9891
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health