Healthcare Provider Details

I. General information

NPI: 1467153080
Provider Name (Legal Business Name): LOGAN WEST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY STE 304
ANNAPOLIS MD
21401-3745
US

IV. Provider business mailing address

3 ADMIRAL RD
SEVERNA PARK MD
21146-3701
US

V. Phone/Fax

Practice location:
  • Phone: 410-573-9530
  • Fax: 667-204-7229
Mailing address:
  • Phone: 443-758-4743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberR246267
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: