Healthcare Provider Details

I. General information

NPI: 1942503602
Provider Name (Legal Business Name): C DIANE REYNOLDS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLARA DIANE TIMM APN

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST
PEORIA IL
61602-1005
US

IV. Provider business mailing address

12156 N TALL TREES DR
DUNLAP IL
61525-9533
US

V. Phone/Fax

Practice location:
  • Phone: 309-353-0388
  • Fax:
Mailing address:
  • Phone: 309-264-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277000768
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number277.000768
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: