Provider Demographics
NPI:1932900396
Name:MILLSTROM, ILAN (RN)
Entity type:Individual
Prefix:
First Name:ILAN
Middle Name:
Last Name:MILLSTROM
Suffix:
Gender:X
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440031
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-0001
Mailing Address - Country:US
Mailing Address - Phone:646-450-2495
Mailing Address - Fax:
Practice Address - Street 1:2 CONSTITUTION PLZ
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-2021
Practice Address - Country:US
Practice Address - Phone:617-724-9852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MARN2391393163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse