Healthcare Provider Details

I. General information

NPI: 1841169737
Provider Name (Legal Business Name): TAMMY SUE GUSTAFSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

IV. Provider business mailing address

N9238 NORWAY LAKE RD
FELCH MI
49831-8854
US

V. Phone/Fax

Practice location:
  • Phone: 906-282-9502
  • Fax:
Mailing address:
  • Phone: 906-282-9502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704265274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: