Provider Demographics
NPI:1770797896
Name:NOVAK, NICHOLE L
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:L
Last Name:NOVAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:L
Other - Last Name:KORTAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 CLEARWATER AVENUE
Mailing Address - Street 2:PO BOX 124
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651
Mailing Address - Country:US
Mailing Address - Phone:313-702-6424
Mailing Address - Fax:
Practice Address - Street 1:9249 W LAKE CITY RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9602
Practice Address - Country:US
Practice Address - Phone:989-839-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist