Provider Demographics
NPI:1225365943
Name:GUSTAFSON, TATYANA (RN, CNS, FPMHNP)
Entity Type:Individual
Prefix:MS
First Name:TATYANA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:RN, CNS, FPMHNP
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Mailing Address - Street 1:5424 W HIGHWAY 290 STE 108
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8827
Mailing Address - Country:US
Mailing Address - Phone:512-430-1130
Mailing Address - Fax:512-677-6806
Practice Address - Street 1:5424 W HIGHWAY 290 STE 108
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8827
Practice Address - Country:US
Practice Address - Phone:512-430-1130
Practice Address - Fax:512-677-6806
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX710364364SA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health