Provider Demographics
NPI:1659632693
Name:STOUT, MARTINA MARIA
Entity Type:Individual
Prefix:MRS
First Name:MARTINA
Middle Name:MARIA
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARTINA
Other - Middle Name:MARIA
Other - Last Name:GIAMBRONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 W 86TH ST
Practice Address - Street 2:APT 3D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3603
Practice Address - Country:US
Practice Address - Phone:212-732-5427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY629493051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist