Healthcare Provider Details

I. General information

NPI: 1740708676
Provider Name (Legal Business Name): LAZEDRICK LOGAN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 09/17/2022
Certification Date: 09/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 N CENTRAL EXPY STE 900
DALLAS TX
75204-2120
US

IV. Provider business mailing address

4131 N CENTRAL EXPY STE 900
DALLAS TX
75204-2120
US

V. Phone/Fax

Practice location:
  • Phone: 800-909-7140
  • Fax:
Mailing address:
  • Phone: 800-909-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number829535
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1032186
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95008515
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1032186
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: