Provider Demographics
NPI:1235712746
Name:BACON, LAURA (DNP, APRN-CNS, RNCOB)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:DNP, APRN-CNS, RNCOB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4707
Practice Address - Country:US
Practice Address - Phone:480-412-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60963722163W00000X
AZRN190158163WP1700X, 163WX0002X
AZCNS275227364SW0102X, 364SP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP1700XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerinatal
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP1700XNursing Service ProvidersRegistered NursePerinatal
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
No163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk