Provider Demographics
NPI:1144068552
Name:GUSTAFSON, REBECCA JO (ND)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-2048
Mailing Address - Country:US
Mailing Address - Phone:608-214-2888
Mailing Address - Fax:
Practice Address - Street 1:114 FS DR STE A
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-2248
Practice Address - Country:US
Practice Address - Phone:608-214-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6064-170175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath