Basic Information
| Provider Information | |||||||||
| NPI: | 1669009007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | KYLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4806 BAKERSFIELD DR | ||||||||
| Address2: | |||||||||
| City: | NESBIT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386516013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014907046 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 WESLEY DR | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381166499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015163700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0000027176 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.