Provider Demographics
NPI:1396203626
Name:LOGAN, AUVIA L (RD, LD)
Entity Type:Individual
Prefix:
First Name:AUVIA
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 S RED CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-5857
Mailing Address - Country:US
Mailing Address - Phone:417-569-6788
Mailing Address - Fax:
Practice Address - Street 1:3322 S. CAMPBELL AVE. SUITE CC
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-719-1700
Practice Address - Fax:417-815-6191
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012010024133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty