Healthcare Provider Details

I. General information

NPI: 1821359951
Provider Name (Legal Business Name): JACQUELINE LYTTLE REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE MCKOY R.N.

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45A CHARLESBANK WAY
WALTHAM MA
02453-2501
US

IV. Provider business mailing address

45A CHARLESBANK WAY
WALTHAM MA
02453-2501
US

V. Phone/Fax

Practice location:
  • Phone: 617-538-2071
  • Fax:
Mailing address:
  • Phone: 617-538-2071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN215766
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: