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General NPI Number Information
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NPI Number | 1407670987
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Entity Type | Individual
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Provider Name | MARY ELIZABETH BACON RN BSN CCM
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Gender | Female
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Dates
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Enumeration Date | 11/12/2024
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 620 JOHN PAUL JONES CIR STE 275
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City | PORTSMOUTH
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State | VA
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Zip | 23708-2197
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Country | US
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Telephone | 757-953-0612
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Fax |
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Provider Business Mailing Address
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Address Line | 126 CONWAY AVE
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City | NORFOLK
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State | VA
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Zip | 23505-4422
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Country | US
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Telephone | 757-403-1679
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WC0400X
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Taxonomy Name | Case Management Registered Nurse
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License Number | 0001078291
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License Number State | VA
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