Healthcare Provider Details

I. General information

NPI: 1699184432
Provider Name (Legal Business Name): LAURA DENISE MANCUSO PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 W SPRUCE AVE
WASILLA AK
99654-5327
US

IV. Provider business mailing address

1363 W SPRUCE AVE
WASILLA AK
99654-5327
US

V. Phone/Fax

Practice location:
  • Phone: 907-352-2411
  • Fax:
Mailing address:
  • Phone: 480-798-1903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP1105
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number199153
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: