Provider Demographics
NPI:1225387475
Name:PEAVY, SHAQUELA D
Entity Type:Individual
Prefix:
First Name:SHAQUELA
Middle Name:D
Last Name:PEAVY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 EMBRUN CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-3460
Mailing Address - Country:US
Mailing Address - Phone:330-550-0641
Mailing Address - Fax:
Practice Address - Street 1:1003 EMBRUN CT
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-3460
Practice Address - Country:US
Practice Address - Phone:330-550-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376K00000X
OH401212700311376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide