Provider Demographics
NPI:1821359951
Name:LYTTLE, JACQUELINE (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:LYTTLE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MCKOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:45A CHARLESBANK WAY
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2501
Mailing Address - Country:US
Mailing Address - Phone:617-538-2071
Mailing Address - Fax:
Practice Address - Street 1:45A CHARLESBANK WAY
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2501
Practice Address - Country:US
Practice Address - Phone:617-538-2071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN215766163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse