Provider Demographics
NPI:1891356721
Name:DIAZ, MARYAM A (DNP FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DNP FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W TAYLOR ST STE 1C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4795
Mailing Address - Country:US
Mailing Address - Phone:312-413-3631
Mailing Address - Fax:
Practice Address - Street 1:1801 W TAYLOR ST STE 1C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-413-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041407865163WG0000X
IL209019748363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice