Healthcare Provider Details

I. General information

NPI: 1396395646
Provider Name (Legal Business Name): BROOKE E. GUSTAFSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 24TH WAY SW STE A2
OLYMPIA WA
98502-6033
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-742-5002
  • Fax:
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN60887665
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: