Basic Information
| Provider Information | |||||||||
| NPI: | 1144996224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULAZA | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MUKAMUSONI | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 W TOUHY AVE APT 1A | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606262631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735468782 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE EVANSTON, IL 60201 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2021 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.022042 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | FNP | 05 | IL | MEDICAID |