Healthcare Provider Details

I. General information

NPI: 1396207049
Provider Name (Legal Business Name): STACEY PEEL CARROLL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY ANNE JURISCH

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 06/14/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 W MOANA LN STE 300
RENO NV
89509-4980
US

IV. Provider business mailing address

1664 N VIRGINIA ST # MS 0316
RENO NV
89557-0001
US

V. Phone/Fax

Practice location:
  • Phone: 775-682-8497
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA199217
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLL4617
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: