Provider Demographics
NPI:1437542016
Name:GUSTIN, MALLORY LYNN (APRN, CNP)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:LYNN
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1700 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1930
Mailing Address - Country:US
Mailing Address - Phone:763-682-1313
Mailing Address - Fax:763-581-9090
Practice Address - Street 1:1001 HART BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8929
Practice Address - Country:US
Practice Address - Phone:763-295-2921
Practice Address - Fax:763-271-3807
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 3741363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology