Provider Demographics
NPI:1073667754
Name:GROLLER, SUSAN ANNE (RN, LAC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANNE
Last Name:GROLLER
Suffix:
Gender:F
Credentials:RN, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14251 73RD AVE NE APT A202
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-4992
Mailing Address - Country:US
Mailing Address - Phone:425-820-2332
Mailing Address - Fax:
Practice Address - Street 1:17311 135TH AVE NE
Practice Address - Street 2:SUITE B300
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-3519
Practice Address - Country:US
Practice Address - Phone:425-737-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002867171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist