Provider Demographics
NPI:1174904452
Name:GUSTAS, MARTHA (LPN)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:GUSTAS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14340 41ST AVE APT 5L
Mailing Address - Street 2:FLUSHING
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-1829
Mailing Address - Country:US
Mailing Address - Phone:917-200-8870
Mailing Address - Fax:
Practice Address - Street 1:85 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4429
Practice Address - Country:US
Practice Address - Phone:171-882-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206380164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse