Healthcare Provider Details

I. General information

NPI: 1457658288
Provider Name (Legal Business Name): PRUDENCE LOGAN ST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 BOEYKENS PL STE 2A
NORMAL IL
61761-2152
US

IV. Provider business mailing address

112 BOEYKENS PL STE 2A
NORMAL IL
61761-2152
US

V. Phone/Fax

Practice location:
  • Phone: 309-846-4716
  • Fax: 309-454-7348
Mailing address:
  • Phone: 309-846-4716
  • Fax: 309-454-7348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: