Provider Demographics
NPI:1205214350
Name:GUSTAFSON, SUSAN STEPHANIE (LPN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:STEPHANIE
Last Name:GUSTAFSON
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 1:7951 250TH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8370
Mailing Address - Country:US
Mailing Address - Phone:651-231-2048
Mailing Address - Fax:
Practice Address - Street 1:7951 250TH ST
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-8370
Practice Address - Country:US
Practice Address - Phone:651-231-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-09
Last Update Date:2015-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL71970-2164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse