MEDICARE: SHELBY LYNN LOGSDON FNP-C

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	207R00000X	Internal Medicine Physician	34-00-6722	OH
2	363A00000X	Physician Assistant	APRN.CNP.023888	OH
3	363LF0000X	Family Nurse Practitioner	APRN.CNP.023888	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598230856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY LYNN LOGSDON FNP-C

Provider Business Mailing Address
First Line	:	4685 FOREST AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45212-3397
Country	:	US
Telephone Number	:	513-853-6470
Fax Number	:	513-852-8525

Provider Business Practice Location Address
First Line	:	500 HARRIS DR
Second Line	:
City	:	OXFORD
State	:	OH
Zip	:	45056-3640
Country	:	US
Telephone Number	:	513-529-3000
Fax Number	:	513-529-1892

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

Provider Enumeration Date	:	10/12/2018
Last Update Date	:	04/26/2022

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