=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083711055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA LYNNE MONAGHAN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 01/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 N LA GRANGE RD
-----------------------------------------------------
City | LA GRANGE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60526-5622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-485-1020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 331 S RIDGELAND AVE UNIT D
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60302-3599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-386-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 055-0030778
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------