Healthcare Provider Details

I. General information

NPI: 1386355089
Provider Name (Legal Business Name): TRACEY JO GUSTAVESON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 12/13/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14901 CANTRELL RD
LITTLE ROCK AR
72223-4255
US

IV. Provider business mailing address

14901 CANTRELL RD
LITTLE ROCK AR
72223-4255
US

V. Phone/Fax

Practice location:
  • Phone: 501-367-1200
  • Fax:
Mailing address:
  • Phone: 501-367-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR091797
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: