Provider Demographics
NPI:1043924434
Name:BACON, JONNI (RN)
Entity Type:Individual
Prefix:
First Name:JONNI
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 WOOLSEY RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98903-5810
Mailing Address - Country:US
Mailing Address - Phone:406-224-1475
Mailing Address - Fax:
Practice Address - Street 1:401 BUSTER RD
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-9792
Practice Address - Country:US
Practice Address - Phone:509-865-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-177340163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse