Provider Demographics
NPI:1093751711
Name:MANCUSO, LISA S (CRNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:S
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 W CHESTER PIKE STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2336
Mailing Address - Country:US
Mailing Address - Phone:484-337-1260
Mailing Address - Fax:
Practice Address - Street 1:523 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1656
Practice Address - Country:US
Practice Address - Phone:215-956-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP006270C363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018240920001Medicaid