Provider Demographics
NPI:1700256153
Name:ELLIG, DIANE MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:ELLIG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:MACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:430 WARRENVILLE RD STE 310
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1348
Practice Address - Country:US
Practice Address - Phone:630-789-4910
Practice Address - Fax:630-432-6744
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.012905363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily