Provider Demographics
NPI:1619015922
Name:STOUT, SALLY ELIZABETH (DC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ELIZABETH
Last Name:STOUT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1149
Mailing Address - Country:US
Mailing Address - Phone:218-834-3100
Mailing Address - Fax:218-834-3173
Practice Address - Street 1:1026 7TH AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1149
Practice Address - Country:US
Practice Address - Phone:218-834-3100
Practice Address - Fax:218-834-3173
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2096111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor