Provider Demographics
NPI:1194703744
Name:MOUSAW, LAURIE CONROE (CNM)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:CONROE
Last Name:MOUSAW
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:
Practice Address - Street 1:49 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676
Practice Address - Country:US
Practice Address - Phone:315-261-2153
Practice Address - Fax:315-265-2540
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF0009701367A00000X
NY349218163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02146830Medicaid
NYRB0050Medicare PIN