=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396207049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY PEEL CARROLL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2019
-----------------------------------------------------
Last Update Date | 03/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46900 OCEAN VIEW DR
-----------------------------------------------------
City | GUALALA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95445-8458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-884-4005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1664 N VIRGINIA ST # MS 0316
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89557-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A199217
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------