1295922045 NPI number — MRS. MARY JANE RELAMPAGOS MANCUSO FNP

Table of content: MRS. MARY JANE RELAMPAGOS MANCUSO FNP (NPI 1295922045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295922045 NPI number — MRS. MARY JANE RELAMPAGOS MANCUSO FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANCUSO
Provider First Name:
MARY JANE
Provider Middle Name:
RELAMPAGOS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RELAMPAGOS
Provider Other First Name:
MARY JANE
Provider Other Middle Name:
CORPUS
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295922045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1759 CREBS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91784-9297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-922-8060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1113 ALTA AVE
Provider Second Line Business Practice Location Address:
SUITE #110
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-922-8060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  545344 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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