Provider Demographics
NPI:1417782996
Name:GUSTIN, LEIA JO (AGACNP)
Entity type:Individual
Prefix:
First Name:LEIA
Middle Name:JO
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:LEIA
Other - Middle Name:J
Other - Last Name:GUSTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGACNP
Mailing Address - Street 1:3000 COLISEUM DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5963
Mailing Address - Country:US
Mailing Address - Phone:757-736-7250
Mailing Address - Fax:757-224-2198
Practice Address - Street 1:3000 COLISEUM DR STE 200
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-367-2507
Practice Address - Fax:757-224-2198
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024190296363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care