Provider Demographics
NPI:1841584448
Name:GROLL, STACIA KUTTER (MD)
Entity Type:Individual
Prefix:MRS
First Name:STACIA
Middle Name:KUTTER
Last Name:GROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:STACIA
Other - Middle Name:ELIZABETH
Other - Last Name:KUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 12427
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-2427
Mailing Address - Country:US
Mailing Address - Phone:850-297-0114
Mailing Address - Fax:850-297-0314
Practice Address - Street 1:1511 SURGEONS DR
Practice Address - Street 2:STE. B
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4680
Practice Address - Country:US
Practice Address - Phone:850-701-0621
Practice Address - Fax:850-877-6727
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHZ101ZMedicare PIN