Provider Demographics
NPI:1467781088
Name:MOUSAW, KATHRYN D (RN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:D
Last Name:MOUSAW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 IRVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-4112
Mailing Address - Country:US
Mailing Address - Phone:585-271-2363
Mailing Address - Fax:
Practice Address - Street 1:50 IRVINGTON RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4112
Practice Address - Country:US
Practice Address - Phone:585-271-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY490396-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02833003Medicaid