Healthcare Provider Details

I. General information

NPI: 1982932539
Provider Name (Legal Business Name): JEANINE CHRISTINE WAGNER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27780 JEFFERSON AVE
TEMECULA CA
92590-6602
US

IV. Provider business mailing address

28780 SINGLE OAK DR STE 260
TEMECULA CA
92590-5534
US

V. Phone/Fax

Practice location:
  • Phone: 951-290-1406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN348218
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20404
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: