Provider Demographics
NPI:1619355195
Name:STOUT, STACEY A (CNM)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:STOUT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 COLISEUM PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3867
Mailing Address - Country:US
Mailing Address - Phone:478-745-7935
Mailing Address - Fax:478-745-7806
Practice Address - Street 1:650 COLISEUM PL
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3867
Practice Address - Country:US
Practice Address - Phone:478-745-7935
Practice Address - Fax:478-745-7806
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN129909367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife