Provider Demographics
NPI:1326632522
Name:LOGAN-BROWN, GLORY JEAN
Entity Type:Individual
Prefix:
First Name:GLORY
Middle Name:JEAN
Last Name:LOGAN-BROWN
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 1:637 FALLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-3020
Mailing Address - Country:US
Mailing Address - Phone:770-580-9242
Mailing Address - Fax:
Practice Address - Street 1:637 FALLVIEW DR
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-3020
Practice Address - Country:US
Practice Address - Phone:770-580-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102065163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management