Healthcare Provider Details

I. General information

NPI: 1407670987
Provider Name (Legal Business Name): MARY ELIZABETH BACON RN BSN CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR STE 275
PORTSMOUTH VA
23708-2197
US

IV. Provider business mailing address

126 CONWAY AVE
NORFOLK VA
23505-4422
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-0612
  • Fax:
Mailing address:
  • Phone: 757-403-1679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0001078291
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: