Healthcare Provider Details

I. General information

NPI: 1134037187
Provider Name (Legal Business Name): DIANA M WAGNER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 ROTH ST
ELMWOOD PARK NJ
07407-2531
US

IV. Provider business mailing address

7 ROTH ST
ELMWOOD PARK NJ
07407-2531
US

V. Phone/Fax

Practice location:
  • Phone: 201-478-2657
  • Fax:
Mailing address:
  • Phone: 201-478-2657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00184200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: