Provider Demographics
NPI:1417605114
Name:ELLIS, LOGAN LEE (RDN LDN)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDN LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HALLSTEAD
Mailing Address - State:PA
Mailing Address - Zip Code:18822-9544
Mailing Address - Country:US
Mailing Address - Phone:607-372-5336
Mailing Address - Fax:
Practice Address - Street 1:2872 TURNPIKE ST
Practice Address - Street 2:
Practice Address - City:SUSQUEHANNA
Practice Address - State:PA
Practice Address - Zip Code:18847-2771
Practice Address - Country:US
Practice Address - Phone:570-853-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86105199133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered