Provider Demographics
NPI:1740440486
Name:LOGAN, AMANDA LEANNE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEANNE
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:PO BOX 120549
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-0549
Mailing Address - Country:US
Mailing Address - Phone:817-303-4521
Mailing Address - Fax:817-459-2856
Practice Address - Street 1:811 INTERSTATE 20 W
Practice Address - Street 2:#114
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5870
Practice Address - Country:US
Practice Address - Phone:817-784-8268
Practice Address - Fax:817-468-9165
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS633320246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist