Provider Demographics
NPI:1033326624
Name:ROLLER, STACEY JO (ATC)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:JO
Last Name:ROLLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 SW 85TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-8512
Mailing Address - Country:US
Mailing Address - Phone:352-375-4683
Mailing Address - Fax:
Practice Address - Street 1:GALE LEMERAND DRIVE
Practice Address - Street 2:CENTRAL RECEIVING-UAA
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32604
Practice Address - Country:US
Practice Address - Phone:352-375-4683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 16182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer