Provider Demographics
NPI:1588848808
Name:SMITH, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SMITH
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 1:1435 N RANDALL RD
Mailing Address - Street 2:STE 304
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2306
Mailing Address - Country:US
Mailing Address - Phone:847-697-7722
Mailing Address - Fax:847-697-7896
Practice Address - Street 1:1435 N RANDALL RD
Practice Address - Street 2:SUITE 304
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2306
Practice Address - Country:US
Practice Address - Phone:847-697-7722
Practice Address - Fax:847-697-7896
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005723176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-005723OtherLICENSE