Provider Demographics
NPI:1992224166
Name:GUSTAFSON, JILL REENA (CNM)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:REENA
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4948 W KOOTENAI ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2002
Mailing Address - Country:US
Mailing Address - Phone:208-510-0261
Mailing Address - Fax:208-225-4243
Practice Address - Street 1:4948 W KOOTENAI ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2002
Practice Address - Country:US
Practice Address - Phone:208-510-0261
Practice Address - Fax:208-225-4243
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56670163W00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse