Provider Demographics
NPI:1942503602
Name:REYNOLDS, C DIANE (APN)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:DIANE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:CLARA
Other - Middle Name:DIANE
Other - Last Name:TIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:12156 N TALL TREES DR
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9533
Mailing Address - Country:US
Mailing Address - Phone:309-264-0578
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-353-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.000768363LA2100X
IL277000768363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care