Provider Demographics
NPI:1679605588
Name:RUSTAD, KRISTINE ELIZABETH (RN, BSN)
Entity Type:Individual
Prefix:MR
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:RUSTAD
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:ELIZABETH
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:41 LEIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-7712
Mailing Address - Country:US
Mailing Address - Phone:207-847-9272
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2621
Practice Address - Country:US
Practice Address - Phone:207-741-2624
Practice Address - Fax:207-741-2972
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERO46385163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management