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NPI Code Detail

MEDICARE: MRS. TRACEY JO GUSTAVESON RN

MEDICARE: MRS. TRACEY JO GUSTAVESON RN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WC1500XCommunity Health Registered NurseR091797AR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1R091797OTHERARARKANSAS STATE BOARD OF NURSING

General Provider Information

NPI Number : 1386355089
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TRACEY JO GUSTAVESON RN
Provider Business Mailing Address
First Line : 14901 CANTRELL RD
Second Line :
City : LITTLE ROCK
State : AR
Zip : 72223-4255
Country : US
Telephone Number : 501-367-1200
Fax Number :
Provider Business Practice Location Address
First Line : 14901 CANTRELL RD
Second Line :
City : LITTLE ROCK
State : AR
Zip : 72223-4255
Country : US
Telephone Number : 501-367-1200
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/13/2022
Last Update Date : 12/13/2022

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