Provider Demographics
NPI:1841832334
Name:LOGAN, MARKEISHA L
Entity type:Individual
Prefix:
First Name:MARKEISHA
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 1:104 JUNGERMANN RD # F
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1608
Mailing Address - Country:US
Mailing Address - Phone:636-244-2112
Mailing Address - Fax:
Practice Address - Street 1:104 JUNGERMANN RD # F
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1608
Practice Address - Country:US
Practice Address - Phone:636-244-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1437372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO821091387Medicaid