Healthcare Provider Details

I. General information

NPI: 1407194541
Provider Name (Legal Business Name): GAYLE S BACON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2013
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 KEEWAYDIN DR
SALEM NH
03079-2839
US

IV. Provider business mailing address

2 KEEWAYDIN DR
SALEM NH
03079-2839
US

V. Phone/Fax

Practice location:
  • Phone: 800-995-2673
  • Fax: 866-420-1055
Mailing address:
  • Phone: 800-995-2673
  • Fax: 866-420-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number000000000104768
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: