Provider Demographics
NPI:1629410618
Name:GUSTAFSON, KIMBERLY ANNE (PT, DPT)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7616 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2702
Mailing Address - Country:US
Mailing Address - Phone:612-990-0714
Mailing Address - Fax:
Practice Address - Street 1:12000 ELM CREEK BLVD N
Practice Address - Street 2:SUITE #120
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7073
Practice Address - Country:US
Practice Address - Phone:763-420-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist