Provider Demographics
NPI:1750571642
Name:LOGAN, MILLIE JOSIE (NP)
Entity type:Individual
Prefix:MS
First Name:MILLIE
Middle Name:JOSIE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MILLIE
Other - Middle Name:JOSIE
Other - Last Name:DAILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:7274 TIMBERLEY CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8908
Mailing Address - Country:US
Mailing Address - Phone:901-624-8844
Mailing Address - Fax:
Practice Address - Street 1:3175 LENOX PARK BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4260
Practice Address - Country:US
Practice Address - Phone:901-273-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33468511Medicaid
TN33468511Medicaid