Provider Demographics
NPI:1821397456
Name:GILLSON, NATALIE A (MD)
Entity Type:Individual
Prefix:MRS
First Name:NATALIE
Middle Name:A
Last Name:GILLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6050
Mailing Address - Fax:239-343-6051
Practice Address - Street 1:15901 BASS RD
Practice Address - Street 2:SUITE 108
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-343-9890
Practice Address - Fax:239-343-9898
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1274812084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017542100Medicaid