Provider Demographics
NPI:1144578568
Name:GUSTAFSON, NATALIE JANE (NP)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:JANE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 5TH ST SE
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-9702
Mailing Address - Country:US
Mailing Address - Phone:218-666-5941
Mailing Address - Fax:218-666-5099
Practice Address - Street 1:1542 GOLF COURSE RD STE 204
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3555
Practice Address - Country:US
Practice Address - Phone:218-999-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR178810-1363LF0000X
MNCNP0497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily