Provider Demographics
NPI:1811266653
Name:FUSCO, WINIFRED MARY (PTA)
Entity type:Individual
Prefix:MS
First Name:WINIFRED
Middle Name:MARY
Last Name:FUSCO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7104 JUNIPER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-1839
Mailing Address - Country:US
Mailing Address - Phone:917-974-4854
Mailing Address - Fax:
Practice Address - Street 1:9110 146TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-4301
Practice Address - Country:US
Practice Address - Phone:718-523-7408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006219-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant