Healthcare Provider Details

I. General information

NPI: 1508337056
Provider Name (Legal Business Name): LAURA ASHLEY LOGAN MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 E ONTARIO ST
CHICAGO IL
60611-4418
US

IV. Provider business mailing address

680 N LAKE SHORE DR STE 1000
CHICAGO IL
60611-8709
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5060
  • Fax:
Mailing address:
  • Phone: 312-695-0665
  • Fax: 312-695-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.473303
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number225340
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.018539
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: