=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063413375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN CARRIE MANCUSO FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3435 MAIN ST UNIVERSITY OF BUFFALO /MICHAEL HALL
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14214-3001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-829-3316
-----------------------------------------------------
Fax | 716-829-2564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 LAFAYETTE AVE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14222-1448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-885-6507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F330754-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------