Provider Demographics
NPI:1073157996
Name:KROGULL, STEPHANIE S
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:S
Last Name:KROGULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 HIGH POINT DR APT 28
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4822
Mailing Address - Country:US
Mailing Address - Phone:815-601-4013
Mailing Address - Fax:
Practice Address - Street 1:363 FINANCIAL CT UNIT 300
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6671
Practice Address - Country:US
Practice Address - Phone:815-397-3691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020365363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner