Provider Demographics
NPI:1538772652
Name:GROSSMAN, STACY ANN (DNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12593 LOWER SYLVAN RD SW
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-2267
Mailing Address - Country:US
Mailing Address - Phone:218-831-8152
Mailing Address - Fax:
Practice Address - Street 1:12593 LOWER SYLVAN RD SW
Practice Address - Street 2:
Practice Address - City:PILLAGER
Practice Address - State:MN
Practice Address - Zip Code:56473-2267
Practice Address - Country:US
Practice Address - Phone:218-831-8152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7591363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7591Medicaid
MN7591OtherMEDICAID