Healthcare Provider Details

I. General information

NPI: 1962553347
Provider Name (Legal Business Name): REBECCA M. LOGUE ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2007
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14973 W BELL RD
SURPRISE AZ
85374-3236
US

IV. Provider business mailing address

PO BOX 47090
PHOENIX AZ
85068-7090
US

V. Phone/Fax

Practice location:
  • Phone: 623-934-5600
  • Fax: 623-934-5603
Mailing address:
  • Phone: 623-934-5600
  • Fax: 623-934-5603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP1554
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: