Provider Demographics
NPI:1477262228
Name:PRIDGEN, LOGAN BAKER (HIS)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:BAKER
Last Name:PRIDGEN
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-3326
Mailing Address - Country:US
Mailing Address - Phone:252-526-0279
Mailing Address - Fax:
Practice Address - Street 1:704 PLAZA BLVD STE I
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1567
Practice Address - Country:US
Practice Address - Phone:252-526-0279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1148A01237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist