Provider Demographics
NPI:1700346137
Name:MCKENNEY GROFF, STEPHANIE LYNN (DO)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:MCKENNEY GROFF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19710 FISHER AVE STE J
Mailing Address - Street 2:
Mailing Address - City:POOLESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20837-2098
Mailing Address - Country:US
Mailing Address - Phone:301-972-7600
Mailing Address - Fax:
Practice Address - Street 1:19710 FISHER AVE STE J
Practice Address - Street 2:
Practice Address - City:POOLESVILLE
Practice Address - State:MD
Practice Address - Zip Code:20837-2098
Practice Address - Country:US
Practice Address - Phone:301-972-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDH0094080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program