Provider Demographics
NPI:1417147463
Name:LOGAN, KIMBERLY LACYNTHIA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LACYNTHIA
Last Name:LOGAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LAYCINTHIA
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1440 JACKSON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-4109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1440 JACKSON LAKE RD
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-4109
Practice Address - Country:US
Practice Address - Phone:904-377-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9166317363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001458200Medicaid
FLCP312ZMedicare PIN