Provider Demographics
NPI:1497288492
Name:TOMLIANOVICH, DIANA L (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:TOMLIANOVICH
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MEDLIN RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-9531
Mailing Address - Country:US
Mailing Address - Phone:618-292-9999
Mailing Address - Fax:
Practice Address - Street 1:900 W TEMPLE AVE STE 208
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2187
Practice Address - Country:US
Practice Address - Phone:217-342-0211
Practice Address - Fax:217-342-0232
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014810363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMEDICARE GROUP PTAN