Provider Demographics
NPI:1487977815
Name:MANCUSO, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:MANCUSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 679
Mailing Address - Street 2:
Mailing Address - City:GLEN WILD
Mailing Address - State:NY
Mailing Address - Zip Code:12738-0679
Mailing Address - Country:US
Mailing Address - Phone:845-434-4943
Mailing Address - Fax:
Practice Address - Street 1:54 W 40TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-2602
Practice Address - Country:US
Practice Address - Phone:212-354-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-13
Last Update Date:2010-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192273163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse