Provider Demographics
NPI:1225133531
Name:GUSTOFSON, DAWN RENEE (RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:RENEE
Last Name:GUSTOFSON
Suffix:
Gender:F
Credentials:RD, LD, CDE
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-5203
Mailing Address - Fax:515-643-5204
Practice Address - Street 1:411 LAUREL ST STE 3320
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3017
Practice Address - Country:US
Practice Address - Phone:515-643-5203
Practice Address - Fax:515-643-5204
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1021133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI8138Medicare ID - Type Unspecified
IAP48894Medicare UPIN