Provider Demographics
NPI:1164747309
Name:WENGER, LOIS (MSN, ANP)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:WENGER
Suffix:
Gender:F
Credentials:MSN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 POWERS CENTER PT
Mailing Address - Street 2:STE 230
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7148
Mailing Address - Country:US
Mailing Address - Phone:719-282-6106
Mailing Address - Fax:719-282-6106
Practice Address - Street 1:47 WIDEFIELD BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-2126
Practice Address - Country:US
Practice Address - Phone:719-390-4335
Practice Address - Fax:719-390-4566
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO71473363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0934055Medicaid
CO0934055Medicaid