Provider Demographics
NPI:1265916662
Name:NOVAKOWSKI, MISTY (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:NOVAKOWSKI
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1425
Mailing Address - Country:US
Mailing Address - Phone:810-991-1630
Mailing Address - Fax:810-991-1522
Practice Address - Street 1:981 N MILL ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1425
Practice Address - Country:US
Practice Address - Phone:734-624-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704290684163WG0600X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI87-4123790Medicaid
MI802227339OtherPRIVATE PAY HOME HEALTH AIDE AND NURSING CARE