Provider Demographics
NPI:1730635566
Name:WAGNER, JEANNENE ROCHELLE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:JEANNENE
Middle Name:ROCHELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1105
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:5320 N LOVINGTON HWY
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-9139
Practice Address - Country:US
Practice Address - Phone:575-392-1973
Practice Address - Fax:575-392-2030
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR26431163WS0200X
NM03552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1K3729OtherMEDICARE
NM1730635566OtherBCBS