Provider Demographics
NPI:1083079636
Name:STOUT, AMANDA GRACE
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:GRACE
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:GRACE
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:200 STATE HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821
Mailing Address - Country:US
Mailing Address - Phone:570-898-2175
Mailing Address - Fax:
Practice Address - Street 1:200 STATE HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-9103
Practice Address - Country:US
Practice Address - Phone:570-271-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP442733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist