Provider Demographics
NPI:1811445810
Name:GUSTAFSON, KAITLYN MARIE
Entity type:Individual
Prefix:MISS
First Name:KAITLYN
Middle Name:MARIE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 DEBONAIR DR
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-1640
Mailing Address - Country:US
Mailing Address - Phone:607-321-1236
Mailing Address - Fax:
Practice Address - Street 1:969 DEBONAIR DR
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-1640
Practice Address - Country:US
Practice Address - Phone:607-321-1236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer