Healthcare Provider Details

I. General information

NPI: 1336549351
Provider Name (Legal Business Name): HEATHER L LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13241 BARTRAM PARK BLVD SUITE 217
JACKSONVILLE FL
32258-5212
US

IV. Provider business mailing address

13241 BARTRAM PARK BLVD SUITE 217
JACKSONVILLE FL
32258-5212
US

V. Phone/Fax

Practice location:
  • Phone: 904-723-4078
  • Fax: 904-647-9491
Mailing address:
  • Phone: 904-723-4078
  • Fax: 904-647-9491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: