Provider Demographics
NPI:1124784640
Name:WHITELAW, MARISA LAUREN (CNM)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LAUREN
Last Name:WHITELAW
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:LAUREN
Other - Last Name:KREITMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 SOUTH MANNING BLVD
Practice Address - Street 2:3 MCAULEY
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:185-525-1381
Practice Address - Fax:518-525-1717
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY948851163W00000X
FL11015782367A00000X
NY002319176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife