Provider Demographics
NPI:1619686821
Name:BROCKINGTON, TANIQUA
Entity Type:Individual
Prefix:
First Name:TANIQUA
Middle Name:
Last Name:BROCKINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5936 CHANCELLOR ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3826
Mailing Address - Country:US
Mailing Address - Phone:267-320-0045
Mailing Address - Fax:
Practice Address - Street 1:5936 CHANCELLOR ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3826
Practice Address - Country:US
Practice Address - Phone:267-320-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide