Provider Demographics
NPI:1215205471
Name:MANCUSO, SANDRA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 HILTON AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4149
Mailing Address - Country:US
Mailing Address - Phone:315-368-6433
Mailing Address - Fax:315-368-0173
Practice Address - Street 1:1203 HILTON AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4149
Practice Address - Country:US
Practice Address - Phone:315-368-6433
Practice Address - Fax:315-368-0173
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231006163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse