Provider Demographics
NPI:1376520007
Name:STOUT-HERRING, MELISA LAYNE (PT ATC)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:LAYNE
Last Name:STOUT-HERRING
Suffix:
Gender:F
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 NW 120TH CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-1729
Mailing Address - Country:US
Mailing Address - Phone:405-781-9955
Mailing Address - Fax:405-751-9988
Practice Address - Street 1:3333 W HEFNER RD
Practice Address - Street 2:STE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-751-9955
Practice Address - Fax:405-751-9988
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100834080AMedicaid
OK611494900OtherDEPT OF LABOR
OKP00253426OtherRR MEDICARE