Basic Information
| Provider Information | |||||||||
| NPI: | 1376703611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGONER | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1151 W 14TH PL | ||||||||
| Address2: | UNIT 306 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606082845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122260619 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7230 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | ELMWOOD PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607074261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084533000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041259607 | IL | Y | Nursing Service Providers | Registered Nurse | 163W00000X | 28116407A | IN | N | Nursing Service Providers | Registered Nurse |
No ID Information.