Provider Demographics
NPI:1801115340
Name:WAGNER, JANELLE JOY (NP-C)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:JOY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7951 E MAPLEWOOD AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4758
Mailing Address - Country:US
Mailing Address - Phone:303-930-7803
Mailing Address - Fax:039-305-5033
Practice Address - Street 1:1760 E KEN PRATT BLVD STE 301&302
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-5311
Practice Address - Country:US
Practice Address - Phone:303-684-1900
Practice Address - Fax:303-684-1925
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP10340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61605271Medicaid
COCOA206816Medicare PIN