Provider Demographics
NPI:1679144364
Name:LANDRY, JACQUELINE ANN (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:LANDRY
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:MYETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:25 SAWYER AVE
Mailing Address - Street 2:
Mailing Address - City:ATKINSON
Mailing Address - State:NH
Mailing Address - Zip Code:03811-2441
Mailing Address - Country:US
Mailing Address - Phone:508-498-3855
Mailing Address - Fax:
Practice Address - Street 1:323 LOWELL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4659
Practice Address - Country:US
Practice Address - Phone:978-475-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH065494-21163WM0705X
MARN2273331363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical