Provider Demographics
NPI:1164710984
Name:LOGAN, KYLIE G (CD, CLEC)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:G
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CD, CLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SCHOFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-2246
Mailing Address - Country:US
Mailing Address - Phone:860-416-4859
Mailing Address - Fax:
Practice Address - Street 1:101 SCHOFIELD RD
Practice Address - Street 2:
Practice Address - City:WILLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06279-2246
Practice Address - Country:US
Practice Address - Phone:860-416-4859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula