Provider Demographics
NPI:1528366150
Name:MANCUSO, JENNY ROSE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:ROSE
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 GREENMIST DR
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4528
Mailing Address - Country:US
Mailing Address - Phone:631-585-5722
Mailing Address - Fax:
Practice Address - Street 1:556 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2669
Practice Address - Country:US
Practice Address - Phone:631-369-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6357651164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse