Provider Demographics
NPI:1235873449
Name:BACON, ANGELA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:BACON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 GRAND AVE APT 408
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-6145
Mailing Address - Country:US
Mailing Address - Phone:412-908-3972
Mailing Address - Fax:
Practice Address - Street 1:11375 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5409
Practice Address - Country:US
Practice Address - Phone:352-596-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL139305367500000X
PARN593231367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered