Organization
FAMILY PRACTICE BY THE LAKE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELINE LEE WAGNER FNP (OWNER)
(208) 661-1181
Entity
Organization
Contact information
Practice address
1875 N LAKEWOOD DR STE 205, COEUR D ALENE, ID 83814-4928
(208) 966-4087
(208) 966-4031
Mailing address
1875 N LAKEWOOD DR STE 205, COEUR D ALENE, ID 83814-4928
(208) 966-4087
(208) 966-4031
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
09/12/2016
Last updated
03/25/2024
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