Healthcare Provider Details

I. General information

NPI: 1730315508
Provider Name (Legal Business Name): ELIZABETH HELEN LOGUE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2009
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 SAN DIMAS ST STE B
BAKERSFIELD CA
93301-5725
US

IV. Provider business mailing address

15202 THUNDER VALLEY RD
BAKERSFIELD CA
93314-7222
US

V. Phone/Fax

Practice location:
  • Phone: 661-327-8000
  • Fax:
Mailing address:
  • Phone: 661-345-1925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17212
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number701740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: