Provider Demographics
NPI:1902033699
Name:DIVIACCHI, BETH N (FNP-C, ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:N
Last Name:DIVIACCHI
Suffix:
Gender:F
Credentials:FNP-C, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W ILLINOIS ROUTE 60
Mailing Address - Street 2:ATTN: CLINIC
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060
Mailing Address - Country:US
Mailing Address - Phone:847-367-2660
Mailing Address - Fax:
Practice Address - Street 1:3100 W ILLINOIS ROUTE 60
Practice Address - Street 2:ATTN: CLINIC
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060
Practice Address - Country:US
Practice Address - Phone:847-367-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041330785163W00000X
IL209006326363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health