Provider Demographics
NPI:1114690682
Name:FULTON, SHAQUANNA JALEEL (MSP, CBE)
Entity Type:Individual
Prefix:
First Name:SHAQUANNA
Middle Name:JALEEL
Last Name:FULTON
Suffix:
Gender:F
Credentials:MSP, CBE
Other - Prefix:
Other - First Name:SHAQUANNA
Other - Middle Name:
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSP, CBE
Mailing Address - Street 1:27777 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5310
Mailing Address - Country:US
Mailing Address - Phone:248-436-4400
Mailing Address - Fax:
Practice Address - Street 1:27777 INKSTER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5310
Practice Address - Country:US
Practice Address - Phone:248-435-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000Medicaid