Healthcare Provider Details

I. General information

NPI: 1679146302
Provider Name (Legal Business Name): MAKENZIE DISERIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 S 2ND ST
DEKALB IL
60115-4435
US

IV. Provider business mailing address

PO BOX 74008272
CHICAGO IL
60674-8272
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax: 702-977-1496
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.009196
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: