Provider Demographics
NPI:1780072330
Name:STOUT, KELLY LYNN (CPNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:STOUT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SW FOUNTAINVIEW BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-4527
Mailing Address - Country:US
Mailing Address - Phone:772-336-2818
Mailing Address - Fax:
Practice Address - Street 1:1850 SW FOUNTAINVIEW BLVD STE 105
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-4527
Practice Address - Country:US
Practice Address - Phone:772-336-2818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030455363LP0200X
NC213338363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780072330Medicaid
SCNP3486Medicaid
NC1780072330Medicaid