Healthcare Provider Details

I. General information

NPI: 1407889975
Provider Name (Legal Business Name): GLORIA L DIAB CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MADISON ST
JOLIET IL
60435
US

IV. Provider business mailing address

333 N MADISON ST
JOLIET IL
60435
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-6331
  • Fax:
Mailing address:
  • Phone: 815-725-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-220838
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-005055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: