Provider Demographics
NPI:1275592248
Name:STOUT, CAROL MCCONNELL (CNM)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:MCCONNELL
Last Name:STOUT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1578
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-1578
Mailing Address - Country:US
Mailing Address - Phone:928-729-5987
Mailing Address - Fax:928-729-5987
Practice Address - Street 1:CORNER OF RT N12 AND RT N 7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8798
Practice Address - Fax:928-729-8794
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165026367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS36288Medicare UPIN