Provider Demographics
NPI:1720568017
Name:KUSTRON, MARY P
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:KUSTRON
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 1:320 W 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6490
Mailing Address - Country:US
Mailing Address - Phone:219-947-6448
Mailing Address - Fax:219-947-6839
Practice Address - Street 1:320 W 61ST AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6490
Practice Address - Country:US
Practice Address - Phone:219-947-6448
Practice Address - Fax:219-947-6839
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28150133A163W00000X
IN71008629A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse