Provider Demographics
NPI:1972157436
Name:LOGRASSO, SAMANTHA (FNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LOGRASSO
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 1:9128 FARMINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150
Mailing Address - Country:US
Mailing Address - Phone:313-623-2736
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN SUITE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244
Practice Address - Country:US
Practice Address - Phone:877-868-5351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285749363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily