Provider Demographics
NPI:1518706373
Name:FUQUAY, SHARDAYA
Entity type:Individual
Prefix:
First Name:SHARDAYA
Middle Name:
Last Name:FUQUAY
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 1:66 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3302
Mailing Address - Country:US
Mailing Address - Phone:313-415-4772
Mailing Address - Fax:
Practice Address - Street 1:10231 PURITAN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1059
Practice Address - Country:US
Practice Address - Phone:313-731-2871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker