Healthcare Provider Details

I. General information

NPI: 1134887771
Provider Name (Legal Business Name): LAURA GUSTAFSON RN60135160
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 N SCHMIDT ST BLDG 1228
HUNTER AAF GA
31409-5300
US

IV. Provider business mailing address

38 N SCHMIDT ST BLDG 1228
SAVANNAH GA
31409-5300
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-3600
  • Fax:
Mailing address:
  • Phone: 912-435-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN60135160
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: