Provider Demographics
NPI:1962917245
Name:LOGAN, MARY ELIZABETH (CRNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-6549
Mailing Address - Fax:
Practice Address - Street 1:5 N 3RD ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15851-0907
Practice Address - Country:US
Practice Address - Phone:814-653-8222
Practice Address - Fax:814-653-9305
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018275363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP018275OtherCRNP LICENSE