Provider Demographics
NPI:1700511193
Name:GUSTAFSON, GINA A (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:A
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52854 HILL TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9285
Mailing Address - Country:US
Mailing Address - Phone:574-850-9545
Mailing Address - Fax:
Practice Address - Street 1:3000 MURVIHILL RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5960
Practice Address - Country:US
Practice Address - Phone:219-286-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012773A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health