Healthcare Provider Details

I. General information

NPI: 1932472966
Provider Name (Legal Business Name): KARIN ELIZABETH GUSTAFSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 FISH HATCHERY RD
MADISON WI
53715-1909
US

IV. Provider business mailing address

1211 FISH HATCHERY RD
MADISON WI
53715-1909
US

V. Phone/Fax

Practice location:
  • Phone: 608-252-8000
  • Fax: 608-283-7354
Mailing address:
  • Phone: 608-252-8000
  • Fax: 608-283-7354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number148938-32
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number178533-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: