Provider Demographics
NPI:1093070534
Name:CONIGLIO, MALYNDA MARY
Entity Type:Individual
Prefix:MRS
First Name:MALYNDA
Middle Name:MARY
Last Name:CONIGLIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALYNDA
Other - Middle Name:MARY
Other - Last Name:LAMANCUSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS ED
Mailing Address - Street 1:51 SAINT JOHNS PARKSIDE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210
Mailing Address - Country:US
Mailing Address - Phone:716-828-9560
Mailing Address - Fax:716-828-9467
Practice Address - Street 1:51 SAINT JOHNS PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2515
Practice Address - Country:US
Practice Address - Phone:716-828-9560
Practice Address - Fax:716-828-9467
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY455456101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY455456101OtherLICENSE/CERTIFICATE NUMBER