Provider Demographics
NPI:1639835895
Name:THOMAS, LOGAN NICOLE
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:NICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:
Other - Last Name:CROUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 EPPERSON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3478
Mailing Address - Country:US
Mailing Address - Phone:423-745-7500
Mailing Address - Fax:
Practice Address - Street 1:329 WESLEY ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1772
Practice Address - Country:US
Practice Address - Phone:423-631-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30187363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics