Provider Demographics
NPI:1518489640
Name:LOGUE, JUANITA GWEN (LSA)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:GWEN
Last Name:LOGUE
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-0938
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:
Practice Address - Street 1:7218 CRAWFORD ROAD
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226
Practice Address - Country:US
Practice Address - Phone:940-440-0525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246ZC0007X
TXSA00783246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant