Provider Demographics
NPI:1912454455
Name:GUSTAFSON, KATELYN C (NP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:C
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:C
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6401 PRAIRIE ST STE 1700
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7843
Practice Address - Country:US
Practice Address - Phone:231-727-7944
Practice Address - Fax:231-724-7812
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008868363LP2300X
IN71013513A363LX0001X
MI4704373177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912454455Medicaid