Provider Demographics
NPI:1154887529
Name:TRACEY L. NOVAK, ARNP, NP-C
Entity type:Organization
Organization Name:TRACEY L. NOVAK, ARNP, NP-C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER/BILLING
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUMANENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-243-7035
Mailing Address - Street 1:PO BOX 879
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32549-0879
Mailing Address - Country:US
Mailing Address - Phone:850-243-7035
Mailing Address - Fax:850-243-8529
Practice Address - Street 1:124 E MIRACLE STRIP PKWY STE 602
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1991
Practice Address - Country:US
Practice Address - Phone:850-243-7035
Practice Address - Fax:850-243-8529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1740305978OtherINDIVIDUAL NPI