Healthcare Provider Details

I. General information

NPI: 1700293289
Provider Name (Legal Business Name): LYNELLE LOGAN MPAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 AUBURN AVE STE 428
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

2123 AUBURN AVE STE 428
CINCINNATI OH
45219-2906
US

V. Phone/Fax

Practice location:
  • Phone: 513-206-1222
  • Fax: 513-585-2095
Mailing address:
  • Phone: 513-206-1222
  • Fax: 513-585-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.009362RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: