Provider Demographics
NPI:1497126874
Name:GUSTAFSON, MICHELLE R (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W UNIVERSITY DR STE 425
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1897
Mailing Address - Country:US
Mailing Address - Phone:248-650-5864
Mailing Address - Fax:248-650-5865
Practice Address - Street 1:1135 W UNIVERSITY DR STE 425
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1897
Practice Address - Country:US
Practice Address - Phone:248-650-5864
Practice Address - Fax:248-650-5865
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily