Provider Demographics
NPI:1528667748
Name:LOGAN, LYRIC
Entity type:Individual
Prefix:
First Name:LYRIC
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 BEAR CREEK COVE LN
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35456-2942
Mailing Address - Country:US
Mailing Address - Phone:205-792-5375
Mailing Address - Fax:
Practice Address - Street 1:2522 BEAR CREEK COVE LN
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:AL
Practice Address - Zip Code:35456-2942
Practice Address - Country:US
Practice Address - Phone:205-792-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-170068163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1122686982Medicaid