Healthcare Provider Details

I. General information

NPI: 1417481086
Provider Name (Legal Business Name): KAELA SHARAE YATES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAELA SHARAE LANDIS

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

6117 S GREENWOOD AVE APT 3
CHICAGO IL
60637-2721
US

V. Phone/Fax

Practice location:
  • Phone: 872-588-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.153386
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: