Provider Demographics
NPI:1407203821
Name:GUSTAFSON, KESSARIN (ARNP)
Entity Type:Individual
Prefix:
First Name:KESSARIN
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KESSARIN
Other - Middle Name:
Other - Last Name:CHAISAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT.
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2815 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2224
Practice Address - Country:US
Practice Address - Phone:862-284-5000
Practice Address - Fax:863-284-6904
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9331620363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily