Provider Demographics
NPI:1215171368
Name:LOGAN, AMY L (FNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4414
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:STE 140
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-890-4132
Practice Address - Fax:417-890-4140
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO149749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191965758Medicaid
MO431560263OtherTRICARE
MOP01036352OtherRR MCR
MO1215171368Medicaid
MO013268289Medicare PIN