Healthcare Provider Details

I. General information

NPI: 1699133405
Provider Name (Legal Business Name): ALYSSA MANCUSO VARGAS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 06/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

120 EDGEBROOK LN
ROCHESTER NY
14617-4117
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-0866
  • Fax:
Mailing address:
  • Phone: 585-721-6407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberF340306-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number340306
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: