Provider Demographics
NPI:1902460512
Name:LOGUE, KATHLEEN L (APRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:LOGUE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3409
Mailing Address - Country:US
Mailing Address - Phone:850-747-5599
Mailing Address - Fax:850-872-4131
Practice Address - Street 1:401 CECIL G COSTIN SR BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1928
Practice Address - Country:US
Practice Address - Phone:850-229-1043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001805363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily