Provider Demographics
NPI:1912065699
Name:LOGSDON, MIMIA CYNTHIA (ARNP)
Entity Type:Individual
Prefix:
First Name:MIMIA
Middle Name:CYNTHIA
Last Name:LOGSDON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 DUTCHMANS LN
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4713
Mailing Address - Country:US
Mailing Address - Phone:502-897-0697
Mailing Address - Fax:502-897-0658
Practice Address - Street 1:4130 DUTCHMANS LN
Practice Address - Street 2:SUITE 400
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4713
Practice Address - Country:US
Practice Address - Phone:502-897-0697
Practice Address - Fax:502-897-0658
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2758P363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1267816Medicare ID - Type UnspecifiedMEDICARE
KY589814Medicare UPIN