Healthcare Provider Details

I. General information

NPI: 1295283810
Provider Name (Legal Business Name): FAMILY PRACTICE BY THE LAKE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 N LAKEWOOD DR STE 205
COEUR D ALENE ID
83814-4928
US

IV. Provider business mailing address

1875 N LAKEWOOD DR STE 205
COEUR D ALENE ID
83814-4928
US

V. Phone/Fax

Practice location:
  • Phone: 208-966-4087
  • Fax: 208-966-4031
Mailing address:
  • Phone: 208-966-4087
  • Fax: 208-966-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE LEE WAGNER
Title or Position: OWNER
Credential: FNP
Phone: 208-661-1181