Provider Demographics
NPI:1679620215
Name:ASHLEY, CAMILLA (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:ASHLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2026
Mailing Address - Country:US
Mailing Address - Phone:312-938-8774
Mailing Address - Fax:
Practice Address - Street 1:151 N MICHIGAN AVE APT 1012
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7538
Practice Address - Country:US
Practice Address - Phone:312-938-8774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D93422Medicare UPIN
712222Medicare ID - Type Unspecified