Provider Demographics
NPI:1972977908
Name:RETTEW, LOGAN M
Entity type:Individual
Prefix:MRS
First Name:LOGAN
Middle Name:M
Last Name:RETTEW
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 1:1211 HEIDI LN S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2321
Mailing Address - Country:US
Mailing Address - Phone:727-251-2044
Mailing Address - Fax:
Practice Address - Street 1:1211 HEIDI LN S
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2321
Practice Address - Country:US
Practice Address - Phone:727-251-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA320OtherLICENSE