Healthcare Provider Details

I. General information

NPI: 1538411749
Provider Name (Legal Business Name): DANA MARIE LAISE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 BURDETT AVE STE 160
TROY NY
12180-2453
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-326-1620
  • Fax: 518-326-1622
Mailing address:
  • Phone: 518-525-5634
  • Fax: 518-649-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number709342-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF001647-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberMW010286
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number001647
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: