Healthcare Provider Details

I. General information

NPI: 1770165797
Provider Name (Legal Business Name): ELLEN KANTOR JEAN-LOUIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1099
US

IV. Provider business mailing address

55 LINCOLN ST
MEDFORD MA
02155-6745
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-2555
  • Fax:
Mailing address:
  • Phone: 339-368-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number164961
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: