Healthcare Provider Details

I. General information

NPI: 1730729070
Provider Name (Legal Business Name): ELIZABETH MANCUSO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH HARDY

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E DAWSON ST
TYLER TX
75701-2036
US

IV. Provider business mailing address

800 E DAWSON ST
TYLER TX
75701-2036
US

V. Phone/Fax

Practice location:
  • Phone: 903-606-7264
  • Fax: 903-525-1254
Mailing address:
  • Phone: 903-606-7264
  • Fax: 903-525-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1045851
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012932
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: