Healthcare Provider Details

I. General information

NPI: 1316869373
Provider Name (Legal Business Name): KAYLEE LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 E LINCOLN RD
IDAHO FALLS ID
83401-2203
US

IV. Provider business mailing address

1956 S WOODRUFF AVE APT 109
IDAHO FALLS ID
83404-6398
US

V. Phone/Fax

Practice location:
  • Phone: 986-497-3149
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberI75781
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: