Provider Demographics
NPI:1598438095
Name:LOGAN-THOMAS, LALAURA LOUISE (ARNP)
Entity Type:Individual
Prefix:
First Name:LALAURA
Middle Name:LOUISE
Last Name:LOGAN-THOMAS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:LALAURA
Other - Middle Name:L
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN
Mailing Address - Street 1:1613 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-3444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1441 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-383-1900
Practice Address - Fax:563-328-5690
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041387210163W00000X
IAG177211363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty