Provider Demographics
NPI:1679308829
Name:GUSTAFSON, MARY A (RN, BSN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W CORNELL DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1759
Mailing Address - Country:US
Mailing Address - Phone:480-897-6233
Mailing Address - Fax:
Practice Address - Street 1:625 W CORNELL DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1759
Practice Address - Country:US
Practice Address - Phone:480-897-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN152538163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool