Provider Demographics
NPI:1780154062
Name:DONALDSON, TEQUELA YASHAN
Entity type:Individual
Prefix:MRS
First Name:TEQUELA
Middle Name:YASHAN
Last Name:DONALDSON
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:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:SANDERSON
Mailing Address - State:FL
Mailing Address - Zip Code:32087-0163
Mailing Address - Country:US
Mailing Address - Phone:904-408-6638
Mailing Address - Fax:904-409-0012
Practice Address - Street 1:14044 FRIENDSHIP PL
Practice Address - Street 2:
Practice Address - City:SANDERSON
Practice Address - State:FL
Practice Address - Zip Code:32087-2489
Practice Address - Country:US
Practice Address - Phone:904-408-6638
Practice Address - Fax:904-409-0012
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL735303Medicaid