Provider Demographics
NPI:1023481967
Name:MOUSSEAU-YOUNG, KIMBERLY (IBCLC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MOUSSEAU-YOUNG
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 NY HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:WEST SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12196-1929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3736 NY HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:WEST SAND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12196-1929
Practice Address - Country:US
Practice Address - Phone:518-712-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-31
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYL-61566174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN