Provider Demographics
NPI:1407048150
Name:STOUT, KELLEY MAUREEN (ANP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MAUREEN
Last Name:STOUT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:STOUT
Other - Last Name:BARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:166 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1820
Mailing Address - Country:US
Mailing Address - Phone:315-729-0021
Mailing Address - Fax:315-531-2268
Practice Address - Street 1:166 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1820
Practice Address - Country:US
Practice Address - Phone:315-729-0021
Practice Address - Fax:315-531-2268
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF30-302516363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02049594Medicaid
NY02049594Medicaid