Individual
LOGAN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1188 N SALEM RD STE 1, FAYETTEVILLE, AR 72704-8803
(479) 595-0474
(479) 239-5444
Mailing address
2668 E CITIZENS DR STE 5, FAYETTEVILLE, AR 72703-4796
(479) 442-7473
(479) 239-5444
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
110010
IA
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
236
—
DC
01
—
568946544
BCBS
—
01
—
5874
HEALTH PARTNERS
—
Enumeration date
12/05/2022
Last updated
02/02/2026
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