Provider Demographics
NPI:1538109673
Name:GILL, STACEY BUSHNELL (DO)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:BUSHNELL
Last Name:GILL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:BUSHNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:13815 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2069
Practice Address - Country:US
Practice Address - Phone:941-426-4900
Practice Address - Fax:941-423-9422
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81099OtherBCBS
FL018973300Medicaid
FLG95266Medicare UPIN