Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 5988 | AZ |
NPI | 1346374758 |
---|---|
Provider Name | Dr. Stephanie Mancuso |
First Address | Scottsdale, AZ 85260-6635 |
Second Address | Scottsdale, AZ 85260-6635 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2007 |
Last Update Date | 07/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
AZ0941110 | BCBS (01) | AZ |
V05309 | (02) | AZ |