Healthcare Provider Details

I. General information

NPI: 1740142215
Provider Name (Legal Business Name): AMANDA JEAN LOGAN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CROOKED HILL RD
BRENTWOOD NY
11717-1039
US

IV. Provider business mailing address

80 MANOR DR
SHIRLEY NY
11967-4306
US

V. Phone/Fax

Practice location:
  • Phone: 631-231-3232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number355090-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: