MEDICARE: ALEX BACON APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	29956	TN

General Provider Information

NPI Number	:	1093388605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEX BACON APRN

Provider Business Mailing Address
First Line	:	550 FORT SUMMIT WAY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37915-2146
Country	:	US
Telephone Number	:	865-374-0555
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 FORT SUMMIT WAY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37915-2146
Country	:	US
Telephone Number	:	865-374-0555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2021
Last Update Date	:	03/30/2022

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