Provider Demographics
NPI:1043931371
Name:PEDERSEN, DIANA (LAC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W 22ND ST STE 112
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6447
Mailing Address - Country:US
Mailing Address - Phone:630-280-6044
Mailing Address - Fax:
Practice Address - Street 1:350 W 22ND ST STE 112
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6447
Practice Address - Country:US
Practice Address - Phone:630-280-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001614171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist