Provider Demographics
NPI:1265137814
Name:LOGAN, MELINDA SUE (FNP)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:SUE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 W MACON ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62522-2753
Mailing Address - Country:US
Mailing Address - Phone:217-454-6267
Mailing Address - Fax:
Practice Address - Street 1:1110 ARBOR DR STE A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9289
Practice Address - Country:US
Practice Address - Phone:217-413-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily