Provider Demographics
NPI:1164194221
Name:MANCUSO, MADELENE KIRSTEN (PMHNP)
Entity Type:Individual
Prefix:
First Name:MADELENE
Middle Name:KIRSTEN
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:MADELENE
Other - Middle Name:KIRSTEN
Other - Last Name:WEICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3042
Mailing Address - Country:US
Mailing Address - Phone:585-271-2520
Mailing Address - Fax:
Practice Address - Street 1:320 PORTER AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1032
Practice Address - Country:US
Practice Address - Phone:716-829-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403773363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health