Provider Demographics
NPI:1881366839
Name:CAGLE, REGAN WYNN (LMT)
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:WYNN
Last Name:CAGLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SAN MARCO BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8549
Mailing Address - Country:US
Mailing Address - Phone:904-858-7045
Mailing Address - Fax:
Practice Address - Street 1:1325 SAN MARCO BLVD STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8549
Practice Address - Country:US
Practice Address - Phone:904-858-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31903225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist