Provider Demographics
NPI:1295283810
Name:FAMILY PRACTICE BY THE LAKE LLC
Entity type:Organization
Organization Name:FAMILY PRACTICE BY THE LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:208-661-1181
Mailing Address - Street 1:1875 N LAKEWOOD DR STE 205
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4928
Mailing Address - Country:US
Mailing Address - Phone:208-966-4087
Mailing Address - Fax:208-966-4031
Practice Address - Street 1:1875 N LAKEWOOD DR STE 205
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4928
Practice Address - Country:US
Practice Address - Phone:208-966-4087
Practice Address - Fax:208-966-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty