Provider Demographics
NPI:1649247156
Name:LOGAN, NETTIE J (CRNA)
Entity type:Individual
Prefix:
First Name:NETTIE
Middle Name:J
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235022
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 HELTON CT
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1464
Practice Address - Country:US
Practice Address - Phone:256-760-0672
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-015726367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALR80464Medicare UPIN