Provider Demographics
NPI:1376504597
Name:LOGAN, BETTYE BRINSON (FNP)
Entity type:Individual
Prefix:
First Name:BETTYE
Middle Name:BRINSON
Last Name:LOGAN
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-765-4414
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:704 S 5TH ST
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-4147
Practice Address - Country:US
Practice Address - Phone:601-765-4414
Practice Address - Fax:601-765-9141
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR623172363L00000X
MS623172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114365Medicaid
MS7064459OtherAETNA
7923884OtherCIGNA
R80627Medicare UPIN
R80627Medicare UPIN