Provider Demographics
NPI:1851918411
Name:MAHLIS, DIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MAHLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 EMERSON PL
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5741 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:ILLINOIS
Practice Address - Zip Code:60804
Practice Address - Country:UM
Practice Address - Phone:708-222-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant