Provider Demographics
NPI:1275840548
Name:LOGSDON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LOGSDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-1078
Mailing Address - Country:US
Mailing Address - Phone:270-782-7464
Mailing Address - Fax:270-782-8025
Practice Address - Street 1:191 WEST PROFESSIONAL PARK COURT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104
Practice Address - Country:US
Practice Address - Phone:270-782-7464
Practice Address - Fax:270-782-8025
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6563P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily