Provider Demographics
NPI:1770168981
Name:GUSTAFSON, MEREDITH SIMPSON (NP)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:SIMPSON
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:SIMPSON
Other - Last Name:BURBANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:25 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-4718
Mailing Address - Country:US
Mailing Address - Phone:774-238-8060
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6106
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041486987163W00000X
IL209022581363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse