Provider Demographics
NPI:1093599383
Name:RUSTAN, GABRIELLE LYNN (QSP)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:LYNN
Last Name:RUSTAN
Suffix:
Gender:F
Credentials:QSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:BELFIELD
Mailing Address - State:ND
Mailing Address - Zip Code:58622-0304
Mailing Address - Country:US
Mailing Address - Phone:701-690-7654
Mailing Address - Fax:
Practice Address - Street 1:304 3RD ST NW
Practice Address - Street 2:
Practice Address - City:BELFIELD
Practice Address - State:ND
Practice Address - Zip Code:58622-7126
Practice Address - Country:US
Practice Address - Phone:701-690-7654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker