Healthcare Provider Details

I. General information

NPI: 1083862098
Provider Name (Legal Business Name): MARY REBECCA STOLL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4170 CEDAR BLUFF DR
PETOSKEY MI
49770-7627
US

IV. Provider business mailing address

4170 CEDAR BLUFF DR
PETOSKEY MI
49770-7627
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-2230
  • Fax: 231-487-6172
Mailing address:
  • Phone: 231-487-2230
  • Fax: 231-487-6172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberL1397712
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: