Healthcare Provider Details

I. General information

NPI: 1528922564
Provider Name (Legal Business Name): SHAQUANA KELLUM PEER SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 3RD AVE FRNT A
NEW YORK NY
10022-7604
US

IV. Provider business mailing address

4 SUMMIT HILL WAY APT 402
TROY NY
12180-6346
US

V. Phone/Fax

Practice location:
  • Phone: 518-225-5069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: