Provider Demographics
NPI:1306032958
Name:MANCUSO, GWENDOLYN EILLEEN (RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:EILLEEN
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BUTLER DR
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-2507
Mailing Address - Country:US
Mailing Address - Phone:585-359-0476
Mailing Address - Fax:
Practice Address - Street 1:350 PARRISH ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1731
Practice Address - Country:US
Practice Address - Phone:585-396-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000782-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered