Basic Information
| Provider Information | |||||||||
| NPI: | 1699803361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOVAK | ||||||||
| FirstName: | THERESE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122165 DEPT 2165 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942772 | ||||||||
| FaxNumber: | 3374942928 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944900 | ||||||||
| FaxNumber: | 3374944707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN049899 APO2313 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | RN049899 APO2313 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1180157 | 05 | LA | MEDICAID | AP02313 | 01 | LA | STATE LICENSE | OTHER |