Provider Demographics
NPI:1952420333
Name:GUSTAFSON-LARSON, ANN MARIE (RN, CNP)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:MARIE
Last Name:GUSTAFSON-LARSON
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:MS
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 CENTRA CARE CIRCLE #2500
Mailing Address - Street 2:CENTRA CARE CLINIC HEALTH PLAZA / ENDOCRINOLOGY
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-229-5000
Mailing Address - Fax:763-689-7878
Practice Address - Street 1:1900 CENTRA CARE CIRCLE #2500
Practice Address - Street 2:CENTRA CARE CLINIC HEALTH PLAZA / ENDOCRINOLOGY
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-229-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1134133V00000X
MNR-103319-9363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered