Provider Demographics
NPI:1275805954
Name:VAN WAGENEN, SHARLI ELIZABETH (BS)
Entity Type:Individual
Prefix:MRS
First Name:SHARLI
Middle Name:ELIZABETH
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:MISS
Other - First Name:SHARLI
Other - Middle Name:ELIZABETH
Other - Last Name:TRUMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1740 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6375
Mailing Address - Country:US
Mailing Address - Phone:208-346-8866
Mailing Address - Fax:
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-346-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker