Provider Demographics
NPI:1831114750
Name:DUDDLES, DIANE L (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:DUDDLES
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 1:600 N WESTMORELAND RD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1659
Mailing Address - Country:US
Mailing Address - Phone:847-535-6150
Mailing Address - Fax:847-535-7801
Practice Address - Street 1:660 N. WESTMORELAND ROAD
Practice Address - Street 2:LAKE FOREST EMERGENCY DEPT
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:847-535-6150
Practice Address - Fax:847-535-7801
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001910363L00000X
IL209-001910363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00417654OtherRAILROAD MCR
ILP17539Medicare UPIN
ILK31297Medicare PIN
ILK38179Medicare PIN