Provider Demographics
NPI:1326545575
Name:BERTOLLA, STACEE BYRD (CRNP)
Entity Type:Individual
Prefix:
First Name:STACEE
Middle Name:BYRD
Last Name:BERTOLLA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16513 COUNTY ROAD 68
Mailing Address - Street 2:
Mailing Address - City:LOXLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36551-3219
Mailing Address - Country:US
Mailing Address - Phone:251-228-0080
Mailing Address - Fax:
Practice Address - Street 1:1700 CENTER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3301
Practice Address - Country:US
Practice Address - Phone:251-415-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-063545363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics