Healthcare Provider Details

I. General information

NPI: 1376901595
Provider Name (Legal Business Name): JACQUELINE AIMEE DALL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

855 CENTRAL AVE
ALBANY NY
12206-1513
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone: 518-434-5678
  • Fax: 518-434-0732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number421273
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number307572
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2292036
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: