Provider Demographics
NPI:1942278213
Name:GUSTIN, TAMMY JO (CNP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JO
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 TAMARACK TRL
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-1469
Mailing Address - Country:US
Mailing Address - Phone:937-748-1661
Mailing Address - Fax:
Practice Address - Street 1:421 S CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-2487
Practice Address - Country:US
Practice Address - Phone:513-529-3000
Practice Address - Fax:513-529-1892
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-05271363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2160245Medicaid
OHNP05013Medicare PIN
OHNP05015Medicare PIN
OHNP05014Medicare PIN