Provider Demographics
NPI:1639674062
Name:MANNING, TEQUILLA TAVOCKIOUS (MD)
Entity Type:Individual
Prefix:DR
First Name:TEQUILLA
Middle Name:TAVOCKIOUS
Last Name:MANNING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 S WILKES BARRE BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5040
Practice Address - Country:US
Practice Address - Phone:570-829-2621
Practice Address - Fax:570-823-4332
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD474509207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program