# FAMILY PRACTICE BY THE LAKE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295283810
- **Authorized official:** JACQUELINE LEE WAGNER FNP (OWNER)
- **Authorized official phone:** (208) 661-1181

## Contact information

- **Practice address:** 1875 N LAKEWOOD DR STE 205, COEUR D ALENE, ID 83814-4928
- **Practice address phone:** (208) 966-4087
- **Practice address fax:** (208) 966-4031
- **Mailing address:** 1875 N LAKEWOOD DR STE 205, COEUR D ALENE, ID 83814-4928
- **Mailing address phone:** (208) 966-4087
- **Mailing address fax:** (208) 966-4031

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 09/12/2016
- **Last updated:** 03/25/2024