Basic Information
| Provider Information | |||||||||
| NPI: | 1699874511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIMMERMAN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 S GREENLEAF ST | ||||||||
| Address2: | SUITE J | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475998899 | ||||||||
| FaxNumber: | 8475998897 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 S GREENLEAF ST | ||||||||
| Address2: | SUITE J | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475998899 | ||||||||
| FaxNumber: | 8475998897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.