Healthcare Provider Details

I. General information

NPI: 1275375842
Provider Name (Legal Business Name): LOGAN ELIZABETH MAYBERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SCIOTO ST STE 4
URBANA OH
43078-2251
US

IV. Provider business mailing address

900 SCIOTO ST STE 4
URBANA OH
43078-2251
US

V. Phone/Fax

Practice location:
  • Phone: 937-653-4666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: