Provider Demographics
NPI:1689056285
Name:NOVOTNY, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:NOVOTNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:779-696-7342
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:779-696-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-359227163W00000X
IL209-013360363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse