Provider Demographics
NPI:1447598362
Name:WAGNER, JACQUELINE LEE (ARNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LEE
Other - Last Name:CRUZ-AEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1713 E SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5326
Mailing Address - Country:US
Mailing Address - Phone:208-966-4087
Mailing Address - Fax:208-966-4031
Practice Address - Street 1:1713 E SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5326
Practice Address - Country:US
Practice Address - Phone:208-966-4087
Practice Address - Fax:208-966-4031
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1283A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine