Provider Demographics
NPI:1871851774
Name:MABERRY, DIANA
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:MABERRY
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 1:17314 BURR OAK LN
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1608
Mailing Address - Country:US
Mailing Address - Phone:708-566-1519
Mailing Address - Fax:
Practice Address - Street 1:17314 BURR OAK LN
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1608
Practice Address - Country:US
Practice Address - Phone:708-566-1196
Practice Address - Fax:708-335-2823
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL13757343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)