Provider Demographics
NPI:1982879011
Name:GRUKA, STACEY LANE (DNP, ARNP, CNM, MSN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LANE
Last Name:GRUKA
Suffix:
Gender:F
Credentials:DNP, ARNP, CNM, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:720-494-3130
Mailing Address - Fax:720-494-3176
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:720-494-3130
Practice Address - Fax:720-494-3176
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0003341-C-CNM363L00000X
FLAPRN9246057363L00000X
FLARNP9246057367A00000X
CAC-APN.0003341-C-CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000200515Medicaid
FL000102200Medicaid