Provider Demographics
NPI:1992475230
Name:LOGAN, TINA MARIE (CNA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2958 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-5814
Mailing Address - Country:US
Mailing Address - Phone:443-904-0215
Mailing Address - Fax:
Practice Address - Street 1:2958 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-5814
Practice Address - Country:US
Practice Address - Phone:443-904-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL362652251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL362652OtherCERTIFIED NURSING ASSISTANT