Provider Demographics
NPI:1871284620
Name:STOUT, STACIE DAWN
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:DAWN
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CAMBRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-2812
Mailing Address - Country:US
Mailing Address - Phone:304-629-8383
Mailing Address - Fax:
Practice Address - Street 1:19 FREEDOM TRL
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:WV
Practice Address - Zip Code:26621-8079
Practice Address - Country:US
Practice Address - Phone:304-644-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant