Provider Demographics
NPI:1407372923
Name:STOUT, LEIGH ANNE (CGC)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ANNE
Last Name:STOUT
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:LEIGH
Other - Middle Name:A
Other - Last Name:AUTULLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:571 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-588-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74000206A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001244797OtherANTHEM PTAN
IN300021911Medicaid