Provider Demographics
NPI:1023680642
Name:DENSON, DIANE ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:DENSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-5607
Mailing Address - Country:US
Mailing Address - Phone:630-669-2350
Mailing Address - Fax:
Practice Address - Street 1:126 W LAKE ST UPPR
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1004
Practice Address - Country:US
Practice Address - Phone:331-481-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty