Healthcare Provider Details

I. General information

NPI: 1912434671
Provider Name (Legal Business Name): MAYRA YANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 03/23/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W 19TH ST
CHICAGO IL
60623-3501
US

IV. Provider business mailing address

1039 PLEASANT ST APT 2E
OAK PARK IL
60302-3071
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number036-153479
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: