Healthcare Provider Details

I. General information

NPI: 1811798697
Provider Name (Legal Business Name): LENAE E VANWAGNEN MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 GREENWOOD AVE LOWR LEVEL
JACKSON MI
49203-3077
US

IV. Provider business mailing address

1310 GREENWOOD AVE
JACKSON MI
49203-3077
US

V. Phone/Fax

Practice location:
  • Phone: 517-962-0123
  • Fax: 517-201-8067
Mailing address:
  • Phone: 517-962-0123
  • Fax: 517-201-8067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LENAE ELIZABETH VANWAGNEN
Title or Position: OWNER
Credential: MD
Phone: 517-962-0123