Provider Demographics
NPI:1487879854
Name:GUSTAFSON, VICKY KAY (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:KAY
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124174 VINCENTE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553
Mailing Address - Country:US
Mailing Address - Phone:951-924-5551
Mailing Address - Fax:
Practice Address - Street 1:14174 VINCENTE DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3505
Practice Address - Country:US
Practice Address - Phone:951-924-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363657163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse