Provider Demographics
NPI:1386789485
Name:GUSTAFSON, MARIE (RN)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:GUSTAFSON
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 1:8382 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:OTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18942-9688
Mailing Address - Country:US
Mailing Address - Phone:610-847-5708
Mailing Address - Fax:
Practice Address - Street 1:8382 EASTON RD
Practice Address - Street 2:
Practice Address - City:OTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18942-9688
Practice Address - Country:US
Practice Address - Phone:610-847-5708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN563205163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)