MEDICARE: MS. DIANE E MCKENZIE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209003923	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750476248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE E MCKENZIE NP

Provider Business Mailing Address
First Line	:	12311 S MORGAN ST
Second Line	:
City	:	CALUMET PARK
State	:	IL
Zip	:	60827-6222
Country	:	US
Telephone Number	:	708-396-2820
Fax Number	:

Provider Business Practice Location Address
First Line	:	11200 W LINCOLN HWY
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-8208
Country	:	US
Telephone Number	:	815-464-2171
Fax Number	:	815-464-2176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	06/13/2011

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