MEDICARE: KATHLEEN LOGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	566778	NY

General Provider Information

NPI Number	:	1407314347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN LOGAN

Provider Business Mailing Address
First Line	:	4582 LAKE RD
Second Line	:
City	:	WILLIAMSON
State	:	NY
Zip	:	14589-9732
Country	:	US
Telephone Number	:	585-455-6104
Fax Number	:

Provider Business Practice Location Address
First Line	:	4582 LAKE RD
Second Line	:
City	:	WILLIAMSON
State	:	NY
Zip	:	14589-9732
Country	:	US
Telephone Number	:	585-455-6104
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2019
Last Update Date	:	03/11/2019

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Directions to “ KATHLEEN LOGAN ” Practice Location

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