Provider Demographics
NPI:1174520746
Name:NOWAK, LYNNE (MD)
Entity type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:
Last Name:NOWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:
Other - Last Name:WILLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:305 S ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2133
Mailing Address - Country:US
Mailing Address - Phone:618-235-1703
Mailing Address - Fax:618-235-3130
Practice Address - Street 1:305 S ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2133
Practice Address - Country:US
Practice Address - Phone:618-235-1703
Practice Address - Fax:618-235-3130
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108140207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG60393Medicare UPIN
ILK06478Medicare ID - Type Unspecified