Provider Demographics
NPI:1104472810
Name:MANCUSO, ASHLEY E
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:E
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1912
Mailing Address - Country:US
Mailing Address - Phone:585-770-3356
Mailing Address - Fax:
Practice Address - Street 1:164 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1912
Practice Address - Country:US
Practice Address - Phone:585-770-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7384841163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY357730319OtherDRIVES LISCENCE