Provider Demographics
NPI:1689626400
Name:VANWAGNEN, LENAE E (MD)
Entity Type:Individual
Prefix:DR
First Name:LENAE
Middle Name:E
Last Name:VANWAGNEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-4518
Mailing Address - Country:US
Mailing Address - Phone:517-787-4330
Mailing Address - Fax:517-787-4861
Practice Address - Street 1:2100 4TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-4518
Practice Address - Country:US
Practice Address - Phone:517-787-4330
Practice Address - Fax:517-787-4861
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076691174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3503810402OtherBCBS
MI7766500OtherAETNA
MI139374OtherPREFERRED CHOICES
MI4538139Medicaid
MI200000005064OtherPHP