Provider Demographics
NPI:1972060721
Name:GUSTAB, MONIKA (LPN)
Entity Type:Individual
Prefix:
First Name:MONIKA
Middle Name:
Last Name:GUSTAB
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 SHORE FRONT PKWY APT 6A
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-2013
Mailing Address - Country:US
Mailing Address - Phone:917-951-7816
Mailing Address - Fax:
Practice Address - Street 1:265 ASHLAND PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1661
Practice Address - Country:US
Practice Address - Phone:718-858-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331046164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse