Provider Demographics
NPI:1083711055
Name:MONAGHAN, DIANA LYNNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNNE
Last Name:MONAGHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 S RIDGELAND AVE
Mailing Address - Street 2:UNIT D
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3599
Mailing Address - Country:US
Mailing Address - Phone:708-386-1030
Mailing Address - Fax:
Practice Address - Street 1:321 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-5622
Practice Address - Country:US
Practice Address - Phone:708-485-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030778363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT055-0030778OtherLICENSE EXPIRES 01/31/20
IL085.003465OtherLICENSE
VT0009284Medicaid
IL085.003465OtherLICENSE
AP2130Medicare PIN