Provider Demographics
NPI:1124620935
Name:ROLLAND, STACIE L (NP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:ROLLAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LYNN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:500 W 3RD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1900
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:
Practice Address - Street 1:1390 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-4831
Practice Address - Country:US
Practice Address - Phone:229-312-7490
Practice Address - Fax:229-312-7495
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF07202315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA231461OtherRN LICENSE