Basic Information
| Provider Information | |||||||||
| NPI: | 1649813288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOUT | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSCCCSLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 N WILLEY ST | ||||||||
| Address2: | |||||||||
| City: | FORT GIBSON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744348235 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1504 N CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744646700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184563456 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2019 | ||||||||
| LastUpdateDate: | 10/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | OK | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.