Healthcare Provider Details

I. General information

NPI: 1497584486
Provider Name (Legal Business Name): MS. SHATAVIA RENEE CAGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WILLIAM ST
CAPE GIRARDEAU MO
63703-5950
US

IV. Provider business mailing address

1900 WILLIAM ST
CAPE GIRARDEAU MO
63703-5950
US

V. Phone/Fax

Practice location:
  • Phone: 573-730-2468
  • Fax:
Mailing address:
  • Phone: 573-730-2468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: