Provider Demographics
NPI:1083227888
Name:MANCUSO, JEREMIAH (RN)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01952-1935
Mailing Address - Country:US
Mailing Address - Phone:781-576-0187
Mailing Address - Fax:
Practice Address - Street 1:39 ELM ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MA
Practice Address - Zip Code:01952-1935
Practice Address - Country:US
Practice Address - Phone:781-576-0187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2274400163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management