Provider Demographics
NPI:1588906820
Name:BROOKS, GLENNTEAYA M (CERTIFICATE)
Entity type:Individual
Prefix:
First Name:GLENNTEAYA
Middle Name:M
Last Name:BROOKS
Suffix:
Gender:F
Credentials:CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-1524
Mailing Address - Country:US
Mailing Address - Phone:856-405-7328
Mailing Address - Fax:
Practice Address - Street 1:413 N LAUREL ST
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-1524
Practice Address - Country:US
Practice Address - Phone:856-405-7328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician