Provider Demographics
NPI:1114286184
Name:YANTIS, ELYSSA RUBERTINO
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:RUBERTINO
Last Name:YANTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELYSSA
Other - Middle Name:RENEE
Other - Last Name:RUBERTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5063
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:4420 DIXIE HWY STE 126
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2994
Practice Address - Country:US
Practice Address - Phone:502-810-3780
Practice Address - Fax:502-394-3607
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4347208000000X
KY04134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics