Provider Demographics
NPI:1982283248
Name:LOGAN, SYDNEY ELIZABETH (LM, CPM)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:ELIZABETH
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2212
Mailing Address - Country:US
Mailing Address - Phone:740-398-4952
Mailing Address - Fax:
Practice Address - Street 1:2301 PARK AVE STE 203
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5558
Practice Address - Country:US
Practice Address - Phone:904-203-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL405176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL405OtherFLORIDA DEPARTMENT OF HEALTH