Provider Demographics
NPI:1427214626
Name:LOGSDON, ROBERTA WOLCOTT (FNP-C)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:WOLCOTT
Last Name:LOGSDON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 BAY BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5081
Mailing Address - Country:US
Mailing Address - Phone:904-287-6426
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9234712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAZ969YMedicare PIN