Individual
MS. CASEY L GUSTAVISON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ANP
Contact information
Practice address
409 W OAK ST, CARBONDALE, IL 62901-1464
(618) 529-4455
(618) 351-1287
Mailing address
PO BOX 3988, CARBONDALE, IL 62902-3988
(618) 457-5200
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209008417
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
71002863A
LICENSE
IN
01
—
71002863B
CSR
IN
05
—
PENDING
—
IN
Enumeration date
01/26/2009
Last updated
10/30/2020
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