Provider Demographics
NPI:1760124663
Name:ANDERTON, DIANE (DNP)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:ANDERTON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3626 W CHARTWELL RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8123
Mailing Address - Country:US
Mailing Address - Phone:309-678-6608
Mailing Address - Fax:
Practice Address - Street 1:3626 W CHARTWELL RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8123
Practice Address - Country:US
Practice Address - Phone:309-678-6608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024993363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner