Provider Demographics
NPI:1649422528
Name:STOUT, KATHY JO (NP-C)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:JO
Last Name:STOUT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:66 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-4582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER045583363LA2200X
MEAP081062363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30347768Medicaid
ME420670099Medicaid
MENP473701Medicare PIN