Provider Demographics
NPI:1619069226
Name:MANCUSO, TRACI (APRN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:PELCHAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4425 E VILLA CASSANDRA WAY
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-9564
Mailing Address - Country:US
Mailing Address - Phone:206-755-6699
Mailing Address - Fax:480-847-2271
Practice Address - Street 1:4425 E VILLA CASSANDRA WAY
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-9564
Practice Address - Country:US
Practice Address - Phone:206-755-6699
Practice Address - Fax:480-847-2271
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ289174363LF0000X
WAAP30006855363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1014638Medicaid
NY02961562Medicaid
WA9644394Medicaid
NYRB3399Medicare PIN
WAG8885735Medicare PIN
WA1014638Medicaid