Provider Demographics
NPI:1700361094
Name:NOWAK, STEPHANIE (APRN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:NOWAK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5607
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 2H
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-574-9136
Practice Address - Fax:321-676-0091
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9411851363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP02202644OtherFL RR MEDICARE
FLKJ379OtherFL MEDICARE