Provider Demographics
NPI:1770234247
Name:KOROM, CSILLA (NP)
Entity Type:Individual
Prefix:
First Name:CSILLA
Middle Name:
Last Name:KOROM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 FORDWAY EXT UNIT 4305
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-7284
Mailing Address - Country:US
Mailing Address - Phone:239-200-2481
Mailing Address - Fax:
Practice Address - Street 1:20 WALL ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4758
Practice Address - Country:US
Practice Address - Phone:781-221-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2316156363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily