Provider Demographics
NPI:1083296313
Name:JUAREZ, KAYLLA MELLANIE
Entity Type:Individual
Prefix:
First Name:KAYLLA
Middle Name:MELLANIE
Last Name:JUAREZ
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 1:1851 WELWYN AVE
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-3134
Mailing Address - Country:US
Mailing Address - Phone:224-595-1730
Mailing Address - Fax:
Practice Address - Street 1:1851 WELWYN AVE
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-3134
Practice Address - Country:US
Practice Address - Phone:224-595-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer