Healthcare Provider Details

I. General information

NPI: 1467317065
Provider Name (Legal Business Name): DENISE MICHELE WAGONER CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TIFFANY DR
REHOBOTH BEACH DE
19971-9729
US

IV. Provider business mailing address

6 TIFFANY DR
REHOBOTH BEACH DE
19971-9729
US

V. Phone/Fax

Practice location:
  • Phone: 302-519-1840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDN-0010836
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberDN-0010836
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: