Provider Demographics
NPI:1457496895
Name:STOUT, PHYLLIS J (FNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:J
Last Name:STOUT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-8099
Practice Address - Fax:417-820-8093
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO052911363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE WEST
MO429683519Medicaid
AR171792758Medicaid
AR171792758Medicaid