Healthcare Provider Details

I. General information

NPI: 1245978915
Provider Name (Legal Business Name): DIANA MATUSIAK CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611
US

IV. Provider business mailing address

601 W JACKSON BLVD UNIT 1307
CHICAGO IL
60661-5642
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 630-335-9882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209024980
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: