Provider Demographics
NPI:1922481894
Name:LOGAN, ALESHA NICOLE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ALESHA
Middle Name:NICOLE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 HOFFMAN RD STE A
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-6557
Mailing Address - Country:US
Mailing Address - Phone:704-865-1749
Mailing Address - Fax:704-865-7328
Practice Address - Street 1:1895 HOFFMAN RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-865-1749
Practice Address - Fax:704-865-7328
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005545A363LF0000X
NC233239363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201300410Medicaid
INP01512421OtherRR MEDICARE
IN266180554Medicare PIN