Healthcare Provider Details

I. General information

NPI: 1407048150
Provider Name (Legal Business Name): KELLEY MAUREEN STOUT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLEY STOUT BARRY

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 SOUTH AVE
PENN YAN NY
14527-1820
US

IV. Provider business mailing address

166 SOUTH AVE
PENN YAN NY
14527-1820
US

V. Phone/Fax

Practice location:
  • Phone: 315-729-0021
  • Fax: 315-531-2268
Mailing address:
  • Phone: 315-729-0021
  • Fax: 315-531-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF30-302516
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: