Provider Demographics
NPI:1679818405
Name:GUSTAFSON, CARMEN MICHELLE (ANP)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MICHELLE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1989 MIAMISBURG CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3859
Mailing Address - Country:US
Mailing Address - Phone:937-528-6890
Mailing Address - Fax:
Practice Address - Street 1:1989 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-3859
Practice Address - Country:US
Practice Address - Phone:937-528-6890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13464-NP364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health