Provider Demographics
NPI:1992505705
Name:BRYAN, SHANQUITA
Entity type:Individual
Prefix:
First Name:SHANQUITA
Middle Name:
Last Name:BRYAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:SHAY
Other - Middle Name:
Other - Last Name:BRYAN-NANCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:682 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2576
Mailing Address - Country:US
Mailing Address - Phone:857-275-3510
Mailing Address - Fax:
Practice Address - Street 1:682 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2576
Practice Address - Country:US
Practice Address - Phone:857-275-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator