Provider Demographics
NPI:1407185226
Name:GUSTIN, VONDA KAY
Entity Type:Individual
Prefix:MS
First Name:VONDA
Middle Name:KAY
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6295 HIGHWAY 74
Mailing Address - Street 2:
Mailing Address - City:ST. GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776
Mailing Address - Country:US
Mailing Address - Phone:225-319-4521
Mailing Address - Fax:225-319-4595
Practice Address - Street 1:6295 HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:ST. GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776
Practice Address - Country:US
Practice Address - Phone:225-319-4521
Practice Address - Fax:225-319-4595
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05957363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health