=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033860598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA POLKOWSKA APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2022
-----------------------------------------------------
Last Update Date | 01/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4440 W 95TH ST
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-612-6133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1307 S WABASH AVE APT 510
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-612-6133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209.024667
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------