Provider Demographics
NPI:1720191794
Name:GUSTIN, SUSAN LYNN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7743
Mailing Address - Country:US
Mailing Address - Phone:810-984-8823
Mailing Address - Fax:
Practice Address - Street 1:3847 PINE GROVE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4265
Practice Address - Country:US
Practice Address - Phone:810-984-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion