Provider Demographics
NPI:1487034633
Name:FENNELL, SHAQUALLA
Entity Type:Individual
Prefix:
First Name:SHAQUALLA
Middle Name:
Last Name:FENNELL
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 1:2800 DESERT SONG DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1334
Mailing Address - Country:US
Mailing Address - Phone:702-741-8066
Mailing Address - Fax:
Practice Address - Street 1:800 W BONAZA RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106
Practice Address - Country:US
Practice Address - Phone:702-968-0231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst