Provider Demographics
NPI:1396037685
Name:GUILLAUME, DIANA (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GUILLAUME
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2718
Mailing Address - Country:US
Mailing Address - Phone:773-724-6200
Mailing Address - Fax:773-866-8015
Practice Address - Street 1:4848 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2718
Practice Address - Country:US
Practice Address - Phone:773-724-6200
Practice Address - Fax:773-866-8015
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008741363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health