Basic Information
| Provider Information | |||||||||
| NPI: | 1063749018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | MARISSA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FAMILY NURSE PRACTIO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738013027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802548600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1101 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738013027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802548600 | ||||||||
| FaxNumber: | 5805718085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2009 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 74435-ARNP | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200264990A | 05 | OK | MEDICAID |