Provider Demographics
NPI:1215197538
Name:LOGUE, LYSSA EDMUNDS (DO, MPH)
Entity Type:Individual
Prefix:
First Name:LYSSA
Middle Name:EDMUNDS
Last Name:LOGUE
Suffix:
Gender:F
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5033 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8240
Mailing Address - Country:US
Mailing Address - Phone:727-334-8523
Mailing Address - Fax:727-292-1164
Practice Address - Street 1:5033 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8240
Practice Address - Country:US
Practice Address - Phone:727-334-8523
Practice Address - Fax:727-292-1164
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO1839390200000X
FLOS11269208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program