Healthcare Provider Details

I. General information

NPI: 1962130682
Provider Name (Legal Business Name): KENNEDY LOGAN CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 E 31ST ST
TULSA OK
74135-5103
US

IV. Provider business mailing address

1408 S SANDUSKY AVE
TULSA OK
74112-6134
US

V. Phone/Fax

Practice location:
  • Phone: 918-932-8164
  • Fax:
Mailing address:
  • Phone: 405-317-3240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: