MEDICARE: MR. LOGAN SCOTT VANSICKLE APRN

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	363LF0000X	Family Nurse Practitioner	3013499	KY

General Provider Information

NPI Number	:	1699335968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LOGAN SCOTT VANSICKLE APRN

Provider Business Mailing Address
First Line	:	1305 N ELM ST
Second Line	:
City	:	HENDERSON
State	:	KY
Zip	:	42420-2775
Country	:	US
Telephone Number	:	270-827-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 LETCHER ST
Second Line	:
City	:	HENDERSON
State	:	KY
Zip	:	42420-4245
Country	:	US
Telephone Number	:	270-831-7950
Fax Number	:

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

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	06/18/2019

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