Healthcare Provider Details

I. General information

NPI: 1831870260
Provider Name (Legal Business Name): LANE GUSTAFSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

643 W NICKERSON ST
SEATTLE WA
98119-1574
US

V. Phone/Fax

Practice location:
  • Phone: 509-703-2183
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP.AP.70118653-NP
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN1355886
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: