Healthcare Provider Details

I. General information

NPI: 1245399930
Provider Name (Legal Business Name): MARY MARGARITA BACON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 GLASS ST
PEMBROKE NH
03275-1506
US

IV. Provider business mailing address

62 ISLAND DR
MERRIMACK NH
03054-4123
US

V. Phone/Fax

Practice location:
  • Phone: 603-485-7788
  • Fax: 603-485-7799
Mailing address:
  • Phone: 603-206-4390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number038972-23-03
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: