Provider Demographics
NPI:1336503721
Name:LOGAN, URSULA (CERT HAIRLOSS SPC)
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CERT HAIRLOSS SPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6491 WINCHESTER RD STE 143
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-4240
Mailing Address - Country:US
Mailing Address - Phone:800-997-0599
Mailing Address - Fax:
Practice Address - Street 1:6491 WINCHESTER RD STE 143
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4240
Practice Address - Country:US
Practice Address - Phone:800-997-0599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000790691744P3200X
335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No335E00000XSuppliersProsthetic/Orthotic Supplier