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General NPI Number Information
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NPI Number | 1083888705
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Entity Type | Individual
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Provider Name | LAVONNE DIANE GUSTAFSON PTA
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Gender | Female
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Dates
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Enumeration Date | 04/14/2008
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Last Update Date | 04/14/2008
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Provider Practice Location Address
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Address Line | 62277 DELTA LAKE RD
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City | IRON RIVER
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State | WI
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Zip | 54847-4570
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Country | US
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Telephone | 715-372-5659
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Fax |
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Provider Business Mailing Address
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Address Line | 62277 DELTA LAKE RD PO BOX 488
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City | IRON RIVER
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State | WI
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Zip | 54847-4570
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Country | US
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Telephone | 715-372-5659
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 1343-019
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License Number State | WI
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