Provider Demographics
NPI:1831663434
Name:CUSUMANO, ELISHA NICCOLE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:NICCOLE
Last Name:CUSUMANO
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 37TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-3624
Mailing Address - Country:US
Mailing Address - Phone:541-335-9787
Mailing Address - Fax:
Practice Address - Street 1:264 HICKEY GYM
Practice Address - Street 2:1 SHIELDS AVE
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:541-335-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer