Healthcare Provider Details

I. General information

NPI: 1649938945
Provider Name (Legal Business Name): NATHAN CHARLES LINGLE AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 12/03/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

IV. Provider business mailing address

109 SUSAN LN
BRANDON MS
39042-3178
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-9503
  • Fax:
Mailing address:
  • Phone: 601-316-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number904952
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: