Provider Demographics
NPI:1689243099
Name:NOVAK, MOLLY (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:NOVAK
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 S HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4242
Mailing Address - Country:US
Mailing Address - Phone:630-220-1693
Mailing Address - Fax:
Practice Address - Street 1:659 S HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4242
Practice Address - Country:US
Practice Address - Phone:630-220-1693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1082476133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered