Healthcare Provider Details

I. General information

NPI: 1679144364
Provider Name (Legal Business Name): JACQUELINE ANN LANDRY MSN, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE ANN MYETTE BSN, RN

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 12/12/2021
Certification Date: 12/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 LOWELL ST
ANDOVER MA
01810-4659
US

IV. Provider business mailing address

25 SAWYER AVE
ATKINSON NH
03811-2441
US

V. Phone/Fax

Practice location:
  • Phone: 978-475-2731
  • Fax:
Mailing address:
  • Phone: 508-498-3855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number065494-21
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2273331
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: