Provider Demographics
NPI:1952897001
Name:OLSEN, DIANA M (APN)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:OLSEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:M
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:1300 DRESDEN DR
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-2476
Practice Address - Country:US
Practice Address - Phone:815-942-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017817363L00000X
IL209.017817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.017817OtherSTATE LICENSE