Provider Demographics
NPI:1649957200
Name:CAMPBELL, SHAQUALA (RN)
Entity type:Individual
Prefix:MRS
First Name:SHAQUALA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RN
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 182
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-0182
Mailing Address - Country:US
Mailing Address - Phone:850-590-5501
Mailing Address - Fax:
Practice Address - Street 1:25058 BLUE STAR HWY
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-7264
Practice Address - Country:US
Practice Address - Phone:850-590-5501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9229071163WC1500X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1720776438Medicaid