Provider Demographics
NPI:1932575503
Name:GLOVER, DIANETTE
Entity type:Individual
Prefix:MRS
First Name:DIANETTE
Middle Name:
Last Name:GLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANETTE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6330 S MAPLEWOOD AVE
Mailing Address - Street 2:2FL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-1626
Mailing Address - Country:US
Mailing Address - Phone:502-294-2195
Mailing Address - Fax:
Practice Address - Street 1:6330 S MAPLEWOOD AVE
Practice Address - Street 2:2FL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1626
Practice Address - Country:US
Practice Address - Phone:502-294-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041305318163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse