Provider Demographics
NPI:1659954709
Name:LOGAN, PRENTISE LESLIE (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:PRENTISE
Middle Name:LESLIE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5648 HIBERNIA DR APT C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-2558
Mailing Address - Country:US
Mailing Address - Phone:614-806-1720
Mailing Address - Fax:
Practice Address - Street 1:6760 TUSSING RD STE 200H
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-4137
Practice Address - Country:US
Practice Address - Phone:614-806-1720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management