Basic Information
| Provider Information | |||||||||
| NPI: | 1457428161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLAN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P, M.S., C.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 MORTON ST | ||||||||
| Address2: | |||||||||
| City: | MATTAPAN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021262834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175332300 | ||||||||
| FaxNumber: | 6175332341 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 MORTON ST | ||||||||
| Address2: | |||||||||
| City: | MATTAPAN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021262834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175332400 | ||||||||
| FaxNumber: | 6175332401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 09/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0807X | 166491 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent | 364SP0808X | 166491 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 364SP0809X | 166491 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 1892819 | 05 | MA | MEDICAID | PN0539 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 166491 | 01 | MA | TUFTS | OTHER |