Provider Demographics
NPI:1871714238
Name:GUSTIN, AMY J (RD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:J
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403
Mailing Address - Country:US
Mailing Address - Phone:509-758-5511
Mailing Address - Fax:509-751-9406
Practice Address - Street 1:1221 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403
Practice Address - Country:US
Practice Address - Phone:509-758-5511
Practice Address - Fax:509-751-9406
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8371114Medicaid
WAAB37192Medicare ID - Type Unspecified