Provider Demographics
NPI:1437102696
Name:GUSTAFSON, KIMBERLY RAE (MN, NNP, ARNP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:RAE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MN, NNP, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 BRIDGEPORT WAY W
Mailing Address - Street 2:PMB #532
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4495
Mailing Address - Country:US
Mailing Address - Phone:253-403-1019
Mailing Address - Fax:
Practice Address - Street 1:315 MLK JR. WAY
Practice Address - Street 2:MS ZO-NTL
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-403-1019
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004020363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal