Provider Demographics
NPI:1396183687
Name:WARNECKE, DIANA (APN, CPNP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:WARNECKE
Suffix:
Gender:F
Credentials:APN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 MIROMAR LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-4020
Mailing Address - Country:US
Mailing Address - Phone:309-258-2555
Mailing Address - Fax:309-624-8884
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:STE 401
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-624-9844
Practice Address - Fax:309-624-8884
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010353363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376000511Medicaid