Provider Demographics
NPI:1821056417
Name:KOURETAS, DIANE (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KOURETAS
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 1:7 BLANCHARD CIR STE 102
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-2038
Mailing Address - Country:US
Mailing Address - Phone:630-682-0500
Mailing Address - Fax:630-682-1078
Practice Address - Street 1:7 BLANCHARD CIR STE 102
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-2038
Practice Address - Country:US
Practice Address - Phone:630-682-0500
Practice Address - Fax:630-682-1078
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004582363L00000X
IL277000351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q27020Medicare UPIN
ILK11857Medicare ID - Type Unspecified