Provider Demographics
NPI:1376901595
Name:DALL, JACQUELINE AIMEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:AIMEE
Last Name:DALL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206
Mailing Address - Country:US
Mailing Address - Phone:518-434-5678
Mailing Address - Fax:518-434-0732
Practice Address - Street 1:855 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206
Practice Address - Country:US
Practice Address - Phone:518-434-5678
Practice Address - Fax:518-434-0732
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307572363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health