Provider Demographics
NPI:1396207049
Name:CARROLL, STACEY PEEL (MD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:PEEL
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANNE
Other - Last Name:JURISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1664 N VIRGINIA ST # MS 0316
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89557-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46900 OCEAN VIEW DR
Practice Address - Street 2:
Practice Address - City:GUALALA
Practice Address - State:CA
Practice Address - Zip Code:95445-8458
Practice Address - Country:US
Practice Address - Phone:707-884-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA199217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine