Provider Demographics
NPI:1538467485
Name:NOWACK, MANDA (RN)
Entity type:Individual
Prefix:MRS
First Name:MANDA
Middle Name:
Last Name:NOWACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 AUTUMN RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3704
Mailing Address - Country:US
Mailing Address - Phone:501-221-1941
Mailing Address - Fax:501-221-1553
Practice Address - Street 1:1014 AUTUMN RD
Practice Address - Street 2:SUITE 4
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3704
Practice Address - Country:US
Practice Address - Phone:501-221-1941
Practice Address - Fax:501-221-1553
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR66975163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse