Healthcare Provider Details

I. General information

NPI: 1841690328
Provider Name (Legal Business Name): SARA DIANA MIRANDA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA DIANA ZAKARIAN

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 W LAKE ST
CHICAGO IL
60644-2342
US

IV. Provider business mailing address

645 S CENTRAL AVE SUITE 600
CHICAGO IL
60644-5059
US

V. Phone/Fax

Practice location:
  • Phone: 773-378-3347
  • Fax:
Mailing address:
  • Phone: 773-537-0020
  • Fax: 773-537-0029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209012136
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: