Basic Information
| Provider Information | |||||||||
| NPI: | 1114286184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YANTIS | ||||||||
| FirstName: | ELYSSA | ||||||||
| MiddleName: | RUBERTINO | ||||||||
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| OtherLastName: | RUBERTINO | ||||||||
| OtherFirstName: | ELYSSA | ||||||||
| OtherMiddleName: | RENEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725063 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 DIXIE HWY STE 126 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402162994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028103780 | ||||||||
| FaxNumber: | 5023943607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 10/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Q4347 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 04134 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.