Healthcare Provider Details

I. General information

NPI: 1962311308
Provider Name (Legal Business Name): LOGAN EDWARD KIRKPATRICK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9248 STATE HIGHWAY 148
BENTON IL
62812-3806
US

IV. Provider business mailing address

9248 STATE HIGHWAY 148
BENTON IL
62812-3806
US

V. Phone/Fax

Practice location:
  • Phone: 618-663-2397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number041.611788
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: