Provider Demographics
NPI:1659579985
Name:KROGGEL, STACEY NICHOLE (OD)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:NICHOLE
Last Name:KROGGEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:104 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8842
Mailing Address - Country:US
Mailing Address - Phone:859-887-2441
Mailing Address - Fax:859-885-3323
Practice Address - Street 1:104 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8842
Practice Address - Country:US
Practice Address - Phone:859-887-2441
Practice Address - Fax:859-885-3323
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1697DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9358804Medicare PIN