Provider Demographics
NPI:1164902359
Name:STOUT, TIFFANY MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:STOUT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:426 E G ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3224
Practice Address - Country:US
Practice Address - Phone:423-547-5950
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000090101164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse