Provider Demographics
NPI:1760805352
Name:GRONDAHL, STEPHANIE (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GRONDAHL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:JARNAGIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6500 38TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 E MICHIGAN AVE STE 460
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1897
Practice Address - Country:US
Practice Address - Phone:517-364-2097
Practice Address - Fax:517-364-3336
Is Sole Proprietor?:No
Enumeration Date:2014-02-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO3557208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice