Provider Demographics
NPI:1386355089
Name:GUSTAVESON, TRACEY JO (RN)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:JO
Last Name:GUSTAVESON
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 1:14901 CANTRELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4255
Mailing Address - Country:US
Mailing Address - Phone:501-367-1200
Mailing Address - Fax:
Practice Address - Street 1:14901 CANTRELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4255
Practice Address - Country:US
Practice Address - Phone:501-367-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR091797163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARR091797OtherARKANSAS STATE BOARD OF NURSING