Healthcare Provider Details

I. General information

NPI: 1619222866
Provider Name (Legal Business Name): DIANE MOORE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041333067
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: