Provider Demographics
NPI:1235772351
Name:STOUTENBURG, ELLAIN JOY DEMAISIP (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:ELLAIN JOY
Middle Name:DEMAISIP
Last Name:STOUTENBURG
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 BROOKWATER CIR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8735
Mailing Address - Country:US
Mailing Address - Phone:806-317-0556
Mailing Address - Fax:
Practice Address - Street 1:2215 E VILLA MARIA RD STE 110
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2585
Practice Address - Country:US
Practice Address - Phone:979-776-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142201363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily