Provider Demographics
NPI:1306183090
Name:LOGSDON, MALLORY ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:LOGSDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5507 S CONGRESS AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1139
Mailing Address - Country:US
Mailing Address - Phone:561-965-6685
Mailing Address - Fax:
Practice Address - Street 1:5507 S CONGRESS AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33462-1139
Practice Address - Country:US
Practice Address - Phone:561-965-6685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant