Healthcare Provider Details

I. General information

NPI: 1831932219
Provider Name (Legal Business Name): LOGAN SCOTT LYLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

IV. Provider business mailing address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number907813
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number915724
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: