Healthcare Provider Details

I. General information

NPI: 1487058343
Provider Name (Legal Business Name): ALYSSA COLLEEN TENDALL STOUT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA COLLEEN TENDALL

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 5TH ST
MARIETTA OH
45750-4033
US

IV. Provider business mailing address

215 5TH ST
MARIETTA OH
45750-4033
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-4575
  • Fax:
Mailing address:
  • Phone: 515-231-1327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT005607
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberAT005607
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005607
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: