Provider Demographics
NPI:1699184432
Name:MANCUSO, LAURA DENISE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:DENISE
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:MSC09 5030
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131
Mailing Address - Country:US
Mailing Address - Phone:480-798-1903
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:MSC09 5030
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131
Practice Address - Country:US
Practice Address - Phone:505-272-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1105363LP0808X
NM63816363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33952213Medicaid