Healthcare Provider Details

I. General information

NPI: 1760805352
Provider Name (Legal Business Name): STEPHANIE GRONDAHL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE JARNAGIN

II. Dates (important events)

Enumeration Date: 02/02/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE STE 460
LANSING MI
48912-1897
US

IV. Provider business mailing address

6500 38TH AVE N
ST PETERSBURG FL
33710-1629
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-2097
  • Fax: 517-364-3336
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberUO3557
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: