Healthcare Provider Details

I. General information

NPI: 1780088443
Provider Name (Legal Business Name): DIANE BOQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28401 N BALLARD DR STE G
LAKE FOREST IL
60045-4543
US

IV. Provider business mailing address

28401 N BALLARD DR STE G
LAKE FOREST IL
60045-4543
US

V. Phone/Fax

Practice location:
  • Phone: 224-212-0624
  • Fax:
Mailing address:
  • Phone: 224-212-0624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.020983
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: