=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689555724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY GUSTAFSON DNP-FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2025
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 KENWOOD AVE
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55811-4199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-447-5444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5515 E BAVARIAN PASS
-----------------------------------------------------
City | FRIDLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55432-6015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | STUDENT
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------