Provider Demographics
NPI:1316075559
Name:SMITH, KYLA NICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:KYLA
Middle Name:NICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KYLA
Other - Middle Name:NICHELLE
Other - Last Name:WIAFE-ABABIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2001 S CALIFORNIA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2486
Mailing Address - Country:US
Mailing Address - Phone:773-584-6200
Mailing Address - Fax:
Practice Address - Street 1:3059 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623
Practice Address - Country:US
Practice Address - Phone:773-584-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1289692080A0000X, 208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.128969Medicaid