Provider Demographics
NPI:1336549351
Name:LOGAN, HEATHER L
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13241 BARTRAM PARK BLVD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5212
Mailing Address - Country:US
Mailing Address - Phone:904-723-4078
Mailing Address - Fax:904-647-9491
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:SUITE 217
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-723-4078
Practice Address - Fax:904-647-9491
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN