MEDICARE: MISS NIKKI DOMINICK STOUT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	0119004666	VA

General Provider Information

NPI Number	:	1639549850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NIKKI DOMINICK STOUT

Provider Business Mailing Address
First Line	:	1825 BLACKWOOD DR
Second Line	:
City	:	MAIDENS
State	:	VA
Zip	:	23102-2526
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 BLACKWOOD DR
Second Line	:
City	:	MAIDENS
State	:	VA
Zip	:	23102-2526
Country	:	US
Telephone Number	:	804-912-0410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2015
Last Update Date	:	05/09/2023

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Directions to “ MISS NIKKI DOMINICK STOUT ” Practice Location

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