Healthcare Provider Details

I. General information

NPI: 1225133531
Provider Name (Legal Business Name): DAWN RENEE GUSTOFSON RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 LAUREL ST STE 3320
DES MOINES IA
50314-3017
US

IV. Provider business mailing address

PO BOX 1475
DES MOINES IA
50305-1475
US

V. Phone/Fax

Practice location:
  • Phone: 515-643-5203
  • Fax: 515-643-5204
Mailing address:
  • Phone: 515-643-5203
  • Fax: 515-643-5204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1021
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1021
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: