Provider Demographics
NPI:1891680229
Name:ETIENNE, MANOUCHKA L (PA-C)
Entity type:Individual
Prefix:
First Name:MANOUCHKA
Middle Name:L
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6548 CONSTANCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7660
Mailing Address - Country:US
Mailing Address - Phone:561-307-7859
Mailing Address - Fax:561-307-7859
Practice Address - Street 1:1600 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-6737
Practice Address - Country:US
Practice Address - Phone:912-289-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13129363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical