Healthcare Provider Details

I. General information

NPI: 1396499760
Provider Name (Legal Business Name): LOGAN REED HEFLIN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8375 HIGHWAY 72 W
MADISON AL
35758-9573
US

IV. Provider business mailing address

101 IRON HORSE TRL
HARVEST AL
35749-8131
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-2012
  • Fax:
Mailing address:
  • Phone: 256-476-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-156065
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: