Provider Demographics
NPI:1316505670
Name:GUSTAFSON, MELISSA JEAN (RN, BSN, OCN, FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:RN, BSN, OCN, FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:WATSEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8700 N GREEN HILLS RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64154-1910
Mailing Address - Country:US
Mailing Address - Phone:913-574-2520
Mailing Address - Fax:913-274-3656
Practice Address - Street 1:8700 N GREEN HILLS RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-1910
Practice Address - Country:US
Practice Address - Phone:913-574-3520
Practice Address - Fax:913-574-2612
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014024546163WX0200X
KS53-80212-062363LF0000X
MO2019023268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0200XNursing Service ProvidersRegistered NurseOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420072547Medicaid
KS201246680AMedicaid