Basic Information
| Provider Information | |||||||||
| NPI: | 1699122119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOUT | ||||||||
| FirstName: | ALYSSA | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 15TH ST STE BI-1056 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067213813 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4300 UNIVERSITY PKWY | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308093063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067218623 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2016 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT003333 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 2626 | MN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | AT003333 | 01 | GA | ATHLETIC TRAINER LICENSE | OTHER |