Provider Demographics
NPI:1124045141
Name:NOVAK, REBECCA RUTH (FNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RUTH
Last Name:NOVAK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 BLAKE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4206
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:970-945-2893
Practice Address - Street 1:1905 BLAKE AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4206
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000634363LF0000X
CA9308363LF0000X
CO0991938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1124045141Medicaid
S89410Medicare UPIN
CA1124045141Medicaid
CADO970ZMedicare PIN