Provider Demographics
NPI:1902652316
Name:WIRTZ, LOGAN DIANE
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:DIANE
Last Name:WIRTZ
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 1:168 FAIRLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-2252
Mailing Address - Country:US
Mailing Address - Phone:440-865-1191
Mailing Address - Fax:
Practice Address - Street 1:168 FAIRLAWN AVE
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-2252
Practice Address - Country:US
Practice Address - Phone:440-865-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver