Healthcare Provider Details

I. General information

NPI: 1750476248
Provider Name (Legal Business Name): DIANE E MCKENZIE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 W LINCOLN HWY
MOKENA IL
60448-8208
US

IV. Provider business mailing address

12311 S MORGAN ST
CALUMET PARK IL
60827-6222
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-2171
  • Fax: 815-464-2176
Mailing address:
  • Phone: 708-396-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209003923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: