Provider Demographics
NPI:1558901041
Name:VAN WAGENEN, PAIGE (HIS11)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:HIS11
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5926
Mailing Address - Country:US
Mailing Address - Phone:309-688-4327
Mailing Address - Fax:
Practice Address - Street 1:8201 GOLF COURSE RD NW STE C2A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-5805
Practice Address - Country:US
Practice Address - Phone:505-295-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3383237700000X
NM0962237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist