Provider Demographics
NPI:1952502064
Name:STOUT, LISA ELAINE (APRN-CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ELAINE
Last Name:STOUT
Suffix:
Gender:F
Credentials:APRN-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6141
Mailing Address - Country:US
Mailing Address - Phone:580-379-5000
Mailing Address - Fax:580-379-5509
Practice Address - Street 1:101 S PARK LN STE 200
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5731
Practice Address - Country:US
Practice Address - Phone:580-379-6140
Practice Address - Fax:580-379-6149
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50604367A00000X
WV161176B00000X
WV75886163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200924150AMedicaid
IN000000522422OtherANTHEM, BCBS
IN000000522422OtherANTHEM, BCBS