Provider Demographics
NPI:1629554878
Name:NOWAK, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NOWAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3134 SEDGEBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-6641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3134 SEDGEBOROUGH DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-6641
Practice Address - Country:US
Practice Address - Phone:408-813-5184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX949130163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse