Provider Demographics
NPI:1184215345
Name:TRAEGER, DIANNE N
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:N
Last Name:TRAEGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8016 SO. IL. ROUTE 23
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152
Mailing Address - Country:US
Mailing Address - Phone:815-451-9865
Mailing Address - Fax:815-568-7397
Practice Address - Street 1:8016 SO. IL. ROUTE 23
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152
Practice Address - Country:US
Practice Address - Phone:815-451-9865
Practice Address - Fax:815-568-7397
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILT62617457621343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)