Healthcare Provider Details

I. General information

NPI: 1689586141
Provider Name (Legal Business Name): LOGAN MARTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5623 W ELK TRAIL ST
EAGLE ID
83714-1837
US

IV. Provider business mailing address

5623 W ELK TRAIL ST
EAGLE ID
83714-1837
US

V. Phone/Fax

Practice location:
  • Phone: 208-391-3782
  • Fax:
Mailing address:
  • Phone: 208-391-3782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number60312
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: