Provider Demographics
NPI:1063797314
Name:DESTEFANO, DIANE LYNN (APRN)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:LYNN
Last Name:DESTEFANO
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 1:1123 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1212
Mailing Address - Country:US
Mailing Address - Phone:618-263-4376
Mailing Address - Fax:618-262-7970
Practice Address - Street 1:1123 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1212
Practice Address - Country:US
Practice Address - Phone:618-263-4376
Practice Address - Fax:618-262-7970
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009671363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209009671OtherILLINOIS APN LICENSE
KY3007204OtherKY LIC
IN71003775AOtherIN LICENSE
IL209009671OtherILLINOIS APN LICENSE