=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992365357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANNA WALTON-TAYLOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2019
-----------------------------------------------------
Last Update Date | 06/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 186 JOYCE LN
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-838-8979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 186 JOYCE LN
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | W43517370867
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------