Provider Demographics
NPI:1710134895
Name:LOGAN, PENNY CAROL (ARNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:CAROL
Last Name:LOGAN
Suffix:
Gender:F
Credentials:ARNP
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 227
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:KY
Mailing Address - Zip Code:42602-0227
Mailing Address - Country:US
Mailing Address - Phone:606-387-8336
Mailing Address - Fax:
Practice Address - Street 1:9057 MANCHESTER HWY
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:TN
Practice Address - Zip Code:37357-5911
Practice Address - Country:US
Practice Address - Phone:931-815-8525
Practice Address - Fax:800-619-7317
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5684P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000582138OtherANTHEM
KY7100061960Medicaid
KY000000582138OtherANTHEM