Individual
MRS. LAVONNE DIANE GUSTAFSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
62277 DELTA LAKE RD, IRON RIVER, WI 54847-4570
(715) 372-5659
Mailing address
62277 DELTA LAKE RD, PO BOX 488, IRON RIVER, WI 54847-4570
(715) 372-5659
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
1343-019
WI
Other
Enumeration date
04/14/2008
Last updated
04/14/2008
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