Provider Demographics
NPI:1114537651
Name:GUSTA, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:GUSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 JEFFERSON DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3816
Mailing Address - Country:US
Mailing Address - Phone:228-641-7561
Mailing Address - Fax:
Practice Address - Street 1:2434 PASS RD # D-13
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2121
Practice Address - Country:US
Practice Address - Phone:228-641-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2023-06-21
Deactivation Date:2023-02-01
Deactivation Code:
Reactivation Date:2023-06-21
Provider Licenses
StateLicense IDTaxonomies
MS216241101YS0200X
MS133994246RP1900X
374U00000X, 101Y00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No374U00000XNursing Service Related ProvidersHome Health Aide
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
861387167OtherMOBILE PHEBOTOMY