Provider Demographics
NPI:1609962497
Name:GUSTITUS, DAWN MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:GUSTITUS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:12243 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-8114
Mailing Address - Country:US
Mailing Address - Phone:810-494-5114
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2335
Practice Address - Country:US
Practice Address - Phone:734-769-7426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704176264363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
5008767250OtherBLUE CROSS BLUE SHIELD
MION43850Medicare ID - Type Unspecified