Healthcare Provider Details

I. General information

NPI: 1508779034
Provider Name (Legal Business Name): DIANA GRACE MEYER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W 95TH ST
EVERGREEN PARK IL
60805-2701
US

IV. Provider business mailing address

353 S FERRY DR
LAKE MILLS WI
53551-1526
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-6200
  • Fax:
Mailing address:
  • Phone: 262-290-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-012529
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: