Provider Demographics
NPI:1952502064
Name:STOUT, LISA E (CNM, MSN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:STOUT
Suffix:
Gender:F
Credentials:CNM, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 SUNCREST TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1876
Mailing Address - Country:US
Mailing Address - Phone:304-599-6353
Mailing Address - Fax:304-598-3608
Practice Address - Street 1:1249 SUNCREST TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1876
Practice Address - Country:US
Practice Address - Phone:304-599-6353
Practice Address - Fax:304-598-3608
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN72000124A176B00000X
WV161176B00000X
WV75886163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200866740Medicaid
IN000000522422OtherANTHEM, BCBS
IN000000522422OtherANTHEM, BCBS