Provider Demographics
NPI:1871842823
Name:KUSTAD, SUSAN RENEE (APRN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:KUSTAD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RENEE
Other - Last Name:MARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:561-798-9417
Mailing Address - Fax:561-798-9419
Practice Address - Street 1:1015 N STATE ROAD 7 STE D
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-5185
Practice Address - Country:US
Practice Address - Phone:561-798-9417
Practice Address - Fax:561-798-9419
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9234339363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104866700Medicaid