Provider Demographics
NPI:1174649826
Name:LOGAN, TRACY L (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 PRESERVE LN
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-1792
Mailing Address - Country:US
Mailing Address - Phone:330-468-8592
Mailing Address - Fax:330-468-8592
Practice Address - Street 1:11090 SCHWAB DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44130-5949
Practice Address - Country:US
Practice Address - Phone:440-888-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 115279164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2687614Medicaid