Provider Demographics
NPI:1861981359
Name:GAZAN, STACEY L (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:GAZAN
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1845 VETERANS PARK DR STE 110
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0493
Practice Address - Country:US
Practice Address - Phone:239-624-1160
Practice Address - Fax:239-624-1161
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9284166363LG0600X
FLARNP9284166363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQZU9SOtherBCBS
FL100227400Medicaid