Healthcare Provider Details

I. General information

NPI: 1770302010
Provider Name (Legal Business Name): MR. JULIA ANN LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1273 S KIRKMAN RD APT 3172
ORLANDO FL
32811-2532
US

IV. Provider business mailing address

1273 S KIRKMAN RD APT 3172
ORLANDO FL
32811-2532
US

V. Phone/Fax

Practice location:
  • Phone: 714-907-3228
  • Fax:
Mailing address:
  • Phone: 714-907-3228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number1231107674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: