Provider Demographics
NPI:1912684036
Name:MCCULLEY, LOGAN WAYNE (NP)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:WAYNE
Last Name:MCCULLEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5432 HIDDEN MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-8320
Mailing Address - Country:US
Mailing Address - Phone:301-277-0068
Mailing Address - Fax:
Practice Address - Street 1:910 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3403
Practice Address - Country:US
Practice Address - Phone:901-448-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN238135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily