=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548756794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUSTIN RICHARD HUSEMANN ACNP-BC, PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2018
-----------------------------------------------------
Last Update Date | 06/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 914 N SAN FRANCISCO ST STE D
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-3254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-985-1495
-----------------------------------------------------
Fax | 928-597-5198
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3159 10TH AVE N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33713-6627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-866-3772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | AP11403
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 209022157
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP11403
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------