Provider Demographics
NPI:1457658288
Name:LOGAN, PRUDENCE (ST)
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:
Last Name:LOGAN
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Gender:F
Credentials:ST
Other - Prefix:
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Mailing Address - Street 1:112 BOEYKENS PL STE 2A
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2152
Mailing Address - Country:US
Mailing Address - Phone:309-846-4716
Mailing Address - Fax:309-454-7348
Practice Address - Street 1:112 BOEYKENS PL STE 2A
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2152
Practice Address - Country:US
Practice Address - Phone:309-846-4716
Practice Address - Fax:309-454-7348
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist