Provider Demographics
NPI:1275940496
Name:LOGUE, KELLIE (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:LOGUE
Suffix:
Gender:F
Credentials:CRNA
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 399
Mailing Address - Street 2:
Mailing Address - City:KREMMLING
Mailing Address - State:CO
Mailing Address - Zip Code:80459-0399
Mailing Address - Country:US
Mailing Address - Phone:309-202-1692
Mailing Address - Fax:
Practice Address - Street 1:214 S 4TH ST
Practice Address - Street 2:
Practice Address - City:KREMMLING
Practice Address - State:CO
Practice Address - Zip Code:80459-5065
Practice Address - Country:US
Practice Address - Phone:970-887-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN185347367500000X
COAPN.0993708-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered