Provider Demographics
NPI:1134954829
Name:DIAZ, ANGELICA MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19110 DARVIN DR STE C
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8683
Mailing Address - Country:US
Mailing Address - Phone:708-765-3899
Mailing Address - Fax:708-765-3939
Practice Address - Street 1:19110 DARVIN DR STE C
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8683
Practice Address - Country:US
Practice Address - Phone:708-765-3899
Practice Address - Fax:708-765-3939
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030448363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner