Provider Demographics
NPI:1437912300
Name:MANQUEN, BROOKELYN DAVIS (CST)
Entity Type:Individual
Prefix:MRS
First Name:BROOKELYN
Middle Name:DAVIS
Last Name:MANQUEN
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 COMMONWEALTH DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4831
Mailing Address - Country:US
Mailing Address - Phone:864-423-6481
Mailing Address - Fax:
Practice Address - Street 1:135 COMMONWEALTH DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4831
Practice Address - Country:US
Practice Address - Phone:864-423-6481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100272089246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty