Healthcare Provider Details

I. General information

NPI: 1225365943
Provider Name (Legal Business Name): TATYANA GUSTAFSON RN, CNS, FPMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 W HIGHWAY 290 STE 108
AUSTIN TX
78735-8827
US

IV. Provider business mailing address

5424 W HIGHWAY 290 STE 108
AUSTIN TX
78735-8827
US

V. Phone/Fax

Practice location:
  • Phone: 512-430-1130
  • Fax: 512-677-6806
Mailing address:
  • Phone: 512-430-1130
  • Fax: 512-677-6806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number710364
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number710364
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: