Provider Demographics
NPI:1295887628
Name:MANCUSO, MARY (FNP)
Entity type:Individual
Prefix:
First Name:MARY
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 1:104 WOODLINE DR
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820
Mailing Address - Country:US
Mailing Address - Phone:607-433-8789
Mailing Address - Fax:
Practice Address - Street 1:SUNY ONEONTA HEALTH SERVICES
Practice Address - Street 2:RAVINE PARKWAY
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820
Practice Address - Country:US
Practice Address - Phone:607-436-3673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334386363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily