Healthcare Provider Details

I. General information

NPI: 1932900396
Provider Name (Legal Business Name): ILAN MILLSTROM RN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CONSTITUTION PLZ
CHARLESTOWN MA
02129-2021
US

IV. Provider business mailing address

PO BOX 440031
SOMERVILLE MA
02144-0001
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-9852
  • Fax:
Mailing address:
  • Phone: 646-450-2495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2391393
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2391393
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: