Provider Demographics
NPI:1124437629
Name:STOUT, ALICIA MARIE
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:PRECOURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:432 NEW BOSTON ST
Mailing Address - Street 2:3
Mailing Address - City:CANASTOTA
Mailing Address - State:NY
Mailing Address - Zip Code:13032-1046
Mailing Address - Country:US
Mailing Address - Phone:315-632-5097
Mailing Address - Fax:
Practice Address - Street 1:432 NEW BOSTON ST
Practice Address - Street 2:3
Practice Address - City:CANASTOTA
Practice Address - State:NY
Practice Address - Zip Code:13032-1046
Practice Address - Country:US
Practice Address - Phone:315-632-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY319236164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse