Provider Demographics
NPI:1891941241
Name:CAGLE, MISTY WALKER (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:WALKER
Last Name:CAGLE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-705-2897
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:50 PARKWAY LN
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3035
Practice Address - Country:US
Practice Address - Phone:601-705-2897
Practice Address - Fax:601-587-6457
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF0708462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04178581Medicaid