Healthcare Provider Details

I. General information

NPI: 1861981359
Provider Name (Legal Business Name): STACEY L GAZAN AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY L BURNS

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 11/03/2023
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 VETERANS PARK DR STE 110
NAPLES FL
34109-0493
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-1160
  • Fax: 239-624-1161
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN9284166
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9284166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: