Provider Demographics
NPI:1437679834
Name:MANCUSO, JESSICA (FNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 SPINDRIFT DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7894
Mailing Address - Country:US
Mailing Address - Phone:716-831-2600
Mailing Address - Fax:
Practice Address - Street 1:297 SPINDRIFT DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7894
Practice Address - Country:US
Practice Address - Phone:716-831-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341884363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04831605Medicaid