MEDICARE: MRS. COLLEEN MARIE BACON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	357546	CA

General Provider Information

NPI Number	:	1184903270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COLLEEN MARIE BACON NP

Provider Business Mailing Address
First Line	:	24422 AVENIDA DE LA CARLOTA STE 300
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-3628
Country	:	US
Telephone Number	:	949-599-2434
Fax Number	:	949-599-2430

Provider Business Practice Location Address
First Line	:	30210 RANCHO VIEJO RD
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1574
Country	:	US
Telephone Number	:	949-493-7337
Fax Number	:	949-493-1418

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2011
Last Update Date	:	05/26/2022

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