Provider Demographics
NPI:1699803361
Name:NOVAK, THERESE ANN (NP)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:ANN
Last Name:NOVAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122108 DEPT 2108
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:1717 OAK PARK BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-494-4900
Practice Address - Fax:337-494-4707
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP02313363LF0000X
LARN049899 APO2313363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1180157Medicaid
LAAP02313OtherSTATE LICENSE