Provider Demographics
NPI:1437334802
Name:ANZELDE, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ANZELDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 CROOKED CREEK RD
Mailing Address - Street 2:204
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-5599
Mailing Address - Country:US
Mailing Address - Phone:847-397-8497
Mailing Address - Fax:
Practice Address - Street 1:2548 CROOKED CREEK RD
Practice Address - Street 2:204
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5599
Practice Address - Country:US
Practice Address - Phone:847-397-8497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA524-1734-4921172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver