Provider Demographics
NPI:1235902198
Name:LUSTIK, KASEY MAUREEN
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:MAUREEN
Last Name:LUSTIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:MAUREEN
Other - Last Name:BRENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3260
Practice Address - Country:US
Practice Address - Phone:386-734-3654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029454363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care