Provider Demographics
NPI:1912787813
Name:DEDIANOUS, ARLETA (APRN)
Entity Type:Individual
Prefix:
First Name:ARLETA
Middle Name:
Last Name:DEDIANOUS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-1748
Mailing Address - Country:US
Mailing Address - Phone:309-308-2000
Mailing Address - Fax:
Practice Address - Street 1:2900 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-1748
Practice Address - Country:US
Practice Address - Phone:309-308-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.002443041.253592363LP0200X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics