Individual
DIANE MARIE WAGONER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
R.N.
Contact information
Practice address
7230 W NORTH AVE, ELMWOOD PARK, IL 60707-4261
(708) 453-3000
Mailing address
1151 W 14TH PL, UNIT 306, CHICAGO, IL 60608-2845
(312) 226-0619
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
041259607
IL
163W00000X
Registered Nurse
28116407A
IN
Other
Enumeration date
06/10/2008
Last updated
06/10/2008
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