Provider Demographics
NPI:1336278969
Name:GUSTAFSON, KERRY N (LMP, ATC, AT/L)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:N
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LMP, ATC, AT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4512
Mailing Address - Country:US
Mailing Address - Phone:360-319-3924
Mailing Address - Fax:
Practice Address - Street 1:1433 N STATE ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4512
Practice Address - Country:US
Practice Address - Phone:360-319-3924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2255A2300X
WAMA60301642225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA22Medicare UPIN