Provider Demographics
NPI:1750536082
Name:BROOKS, DIANE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 W 79TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-1569
Mailing Address - Country:US
Mailing Address - Phone:708-499-1545
Mailing Address - Fax:708-499-4862
Practice Address - Street 1:4901 W 79TH ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1554
Practice Address - Country:US
Practice Address - Phone:708-346-8268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant