Provider Demographics
NPI:1699263798
Name:GROLLER, TRACY L (PMHNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:GROLLER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:484-526-2400
Mailing Address - Fax:833-213-6428
Practice Address - Street 1:1107 EATON AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-1862
Practice Address - Country:US
Practice Address - Phone:484-526-2400
Practice Address - Fax:484-526-3697
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018733363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner