Healthcare Provider Details

I. General information

NPI: 1851721302
Provider Name (Legal Business Name): ELIZABETH LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 HICKORY ST STE B
MELBOURNE FL
32901-1973
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-361-5599
  • Fax: 321-952-6179
Mailing address:
  • Phone: 321-361-5599
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9232775
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: