Provider Demographics
NPI:1639549850
Name:STOUT, NIKKI DOMINICK
Entity Type:Individual
Prefix:MISS
First Name:NIKKI
Middle Name:DOMINICK
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 BLACKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MAIDENS
Mailing Address - State:VA
Mailing Address - Zip Code:23102-2526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1825 BLACKWOOD DR
Practice Address - Street 2:
Practice Address - City:MAIDENS
Practice Address - State:VA
Practice Address - Zip Code:23102-2526
Practice Address - Country:US
Practice Address - Phone:804-912-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004666225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist