1023128386 NPI number — DIANE NEWQUIST PT

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023128386 NPI number — DIANE NEWQUIST PT

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

NEWQUIST

Provider First Name:

DIANE

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

PT

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1023128386

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/28/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

766 BUTTERNUT LN

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ELGIN

Provider Business Mailing Address State Name:

IL

Provider Business Mailing Address Postal Code:

60123-2586

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

847-987-1627

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1213 S MAIN ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ALGONQUIN

Provider Business Practice Location Address State Name:

IL

Provider Business Practice Location Address Postal Code:

60102-2741

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

224-505-3343

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

08/30/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 225100000X , with the licence number:  070005212 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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