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NPI Code Detail

MEDICARE: KATELYN C GUSTAFSON NP

MEDICARE: KATELYN C GUSTAFSON NP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP2300XPrimary Care Nurse Practitioner5008868NC
2363LX0001XObstetrics & Gynecology Nurse Practitioner71013513AIN
3363L00000XNurse Practitioner4704373177MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1912454455
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATELYN C GUSTAFSON NP
Provider Business Mailing Address
First Line : 250 N SHADELAND AVE
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46219-4959
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 6401 PRAIRIE ST STE 1700
Second Line :
City : NORTON SHORES
State : MI
Zip : 49444-7843
Country : US
Telephone Number : 231-727-7944
Fax Number : 231-724-7812
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/01/2016
Last Update Date : 01/25/2023

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Directions to “ KATELYN C GUSTAFSON NP” Practice Location

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