Healthcare Provider Details

I. General information

NPI: 1437658960
Provider Name (Legal Business Name): JONATHAN EDWARD CAUDLE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801
US

IV. Provider business mailing address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone: 662-377-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0993670-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902847
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: