Provider Demographics
NPI:1912476813
Name:MARTINEZ, STEPHANIE GENTRY
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GENTRY
Last Name:MARTINEZ
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 1:1644 W 107TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2906
Mailing Address - Country:US
Mailing Address - Phone:773-203-2573
Mailing Address - Fax:
Practice Address - Street 1:1024 NORTH BLVD STE 208
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1149
Practice Address - Country:US
Practice Address - Phone:708-386-4292
Practice Address - Fax:708-848-4886
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018154367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife