Provider Demographics
NPI:1962665497
Name:VANYO-NOVAK, JENNIFER LYNN (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:VANYO-NOVAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W THUNDERBIRD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4451
Mailing Address - Country:US
Mailing Address - Phone:557-767-2668
Mailing Address - Fax:
Practice Address - Street 1:9000 W THUNDERBIRD RD STE 110
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4451
Practice Address - Country:US
Practice Address - Phone:557-767-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR70147207Q00000X
AZ005562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102156Medicaid