Provider Demographics
NPI:1003096868
Name:STOUT, PRISCILLA (RN)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:STOUT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2253
Mailing Address - Country:US
Mailing Address - Phone:617-898-9045
Mailing Address - Fax:617-296-1421
Practice Address - Street 1:1425 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2253
Practice Address - Country:US
Practice Address - Phone:617-898-9045
Practice Address - Fax:617-296-1421
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA278147163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse