Basic Information
Provider Information | |||||||||
NPI: | 1003560954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOGAN | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3251 3RD AVE N | ||||||||
Address2: |   | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337138506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274984969 | ||||||||
FaxNumber: | 8558965258 | ||||||||
Practice Location | |||||||||
Address1: | 3251 3RD AVE N | ||||||||
Address2: |   | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337138506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274984969 | ||||||||
FaxNumber: | 8558965258 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2022 | ||||||||
LastUpdateDate: | 02/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9275298 | FL | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | RN9275298 | 01 | FL | FLORIDA STAT BOARD OF NURSING | OTHER |