Provider Demographics
NPI:1629930599
Name:NOWACKI, RAYANN
Entity type:Individual
Prefix:
First Name:RAYANN
Middle Name:
Last Name:NOWACKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 E 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-2623
Mailing Address - Country:US
Mailing Address - Phone:219-840-8665
Mailing Address - Fax:
Practice Address - Street 1:4835 E 25TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2623
Practice Address - Country:US
Practice Address - Phone:219-840-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer