Provider Demographics
NPI:1487058343
Name:STOUT, ALYSSA COLLEEN TENDALL (ATC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:COLLEEN TENDALL
Last Name:STOUT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:COLLEEN
Other - Last Name:TENDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-4033
Mailing Address - Country:US
Mailing Address - Phone:515-231-1327
Mailing Address - Fax:
Practice Address - Street 1:215 5TH ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-4033
Practice Address - Country:US
Practice Address - Phone:740-376-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT005607225400000X, 2255A2300X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAT005607OtherATHLETIC TRAINER