Provider Demographics
NPI:1114566841
Name:GROFF, STACIE (MSN, CRNA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:GROFF
Suffix:
Gender:F
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL AVE APT 446
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2290
Mailing Address - Country:US
Mailing Address - Phone:717-779-7756
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC294576367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered