Provider Demographics
NPI:1689190969
Name:GUSTAMA, DANIELLE ALBERTE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:ALBERTE
Last Name:GUSTAMA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13152 232ND ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1836
Mailing Address - Country:US
Mailing Address - Phone:646-377-0096
Mailing Address - Fax:
Practice Address - Street 1:45 E 81ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0263
Practice Address - Country:US
Practice Address - Phone:212-737-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY545039163W00000X
NY307698363LA2200X
NY402807363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health