Provider Demographics
NPI:1508337056
Name:LOGAN, LAURA ASHLEY (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ASHLEY
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8709
Mailing Address - Country:US
Mailing Address - Phone:312-695-0665
Mailing Address - Fax:312-695-6594
Practice Address - Street 1:446 E ONTARIO ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4418
Practice Address - Country:US
Practice Address - Phone:312-695-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.473303163W00000X
TN225340163W00000X
IL209.018539363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse