Provider Demographics
NPI:1912093204
Name:NOVACK, DEBORAH ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:NOVACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 24TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-3245
Mailing Address - Country:US
Mailing Address - Phone:727-898-1054
Mailing Address - Fax:
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:PREOP
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-4128
Practice Address - Fax:727-767-8528
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3182252363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP3182252OtherFLORIDA LICENSE
FL016841600Medicaid
FLY051YMedicare ID - Type Unspecified
FL016841600Medicaid