Provider Demographics
NPI:1700931342
Name:LOGAN, KIMBERLY A (FNPC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 STATE ROAD
Mailing Address - Street 2:
Mailing Address - City:GT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1223
Mailing Address - Country:US
Mailing Address - Phone:413-644-9933
Mailing Address - Fax:413-644-9433
Practice Address - Street 1:63 STATE ROAD
Practice Address - Street 2:
Practice Address - City:GT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1223
Practice Address - Country:US
Practice Address - Phone:413-644-9933
Practice Address - Fax:413-644-9433
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210360363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0799017Medicaid