Healthcare Provider Details

I. General information

NPI: 1972845253
Provider Name (Legal Business Name): KAREN BACON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88-25 163RD ST
JAMAICA NY
11432
US

IV. Provider business mailing address

88-25 163RD STREET
JAMAICA NY
11432
US

V. Phone/Fax

Practice location:
  • Phone: 718-739-0045
  • Fax:
Mailing address:
  • Phone: 718-421-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number712655
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: