Provider Demographics
NPI:1497584486
Name:CAGLE, SHATAVIA RENEE
Entity type:Individual
Prefix:MS
First Name:SHATAVIA
Middle Name:RENEE
Last Name:CAGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5950
Mailing Address - Country:US
Mailing Address - Phone:573-730-2468
Mailing Address - Fax:
Practice Address - Street 1:1900 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5950
Practice Address - Country:US
Practice Address - Phone:573-730-2468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO174200000X, 174H00000X, 225100000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No174200000XOther Service ProvidersMeals
No174H00000XOther Service ProvidersHealth Educator
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist