Provider Demographics
NPI:1366114472
Name:NOWAK, MIKALE NATASHA (NP)
Entity type:Individual
Prefix:
First Name:MIKALE
Middle Name:NATASHA
Last Name:NOWAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MIKALE
Other - Middle Name:NATASHA
Other - Last Name:BELL; WORTHEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1814 SANDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3791
Mailing Address - Country:US
Mailing Address - Phone:319-573-6888
Mailing Address - Fax:
Practice Address - Street 1:831 HIGHWAY 150 S
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3800
Practice Address - Country:US
Practice Address - Phone:307-789-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY45708363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health