Healthcare Provider Details

I. General information

NPI: 1316075559
Provider Name (Legal Business Name): KYLA NICHELLE SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLA NICHELLE WIAFE-ABABIO MD

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3059 W 26TH ST
CHICAGO IL
60623
US

IV. Provider business mailing address

2001 S CALIFORNIA AVE STE 100
CHICAGO IL
60608-2486
US

V. Phone/Fax

Practice location:
  • Phone: 773-584-6200
  • Fax:
Mailing address:
  • Phone: 773-584-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036-128969
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-128969
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: