Healthcare Provider Details

I. General information

NPI: 1093647067
Provider Name (Legal Business Name): TIARA DIANE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 W TAYLOR ST # 236
CHICAGO IL
60607-4623
US

IV. Provider business mailing address

22420 BROOKWOOD DR
SAUK VILLAGE IL
60411-5810
US

V. Phone/Fax

Practice location:
  • Phone: 464-249-4102
  • Fax:
Mailing address:
  • Phone: 464-249-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: