Healthcare Provider Details

I. General information

NPI: 1205767803
Provider Name (Legal Business Name): ASHLEY CRUZ-MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 N BROADWAY ST
CHICAGO IL
60613-4567
US

IV. Provider business mailing address

3641 W LELAND AVE APT 2
CHICAGO IL
60625-6458
US

V. Phone/Fax

Practice location:
  • Phone: 773-496-4433
  • Fax: 773-496-4430
Mailing address:
  • Phone: 312-783-8295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: