Provider Demographics
NPI:1770660011
Name:LOGAN, KAYLEEN A (MS, APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:KAYLEEN
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MS, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 SANTA ANA DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5619
Mailing Address - Country:US
Mailing Address - Phone:307-382-5872
Mailing Address - Fax:307-382-5872
Practice Address - Street 1:1124 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5863
Practice Address - Country:US
Practice Address - Phone:307-352-6680
Practice Address - Fax:307-352-6676
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9567.0079363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1061151-00Medicaid
WY306322Medicare ID - Type Unspecified
WYW4372048Medicare ID - Type UnspecifiedSOUTHWEST COUNSELING #