Provider Demographics
NPI:1326022617
Name:BACON, CHERYL D (CRNA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:D
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 1:257 BROCKENBRAUGH CT.
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005
Mailing Address - Country:US
Mailing Address - Phone:504-289-1594
Mailing Address - Fax:
Practice Address - Street 1:310 N. CAUSEWAY
Practice Address - Street 2:SUITE 404
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002
Practice Address - Country:US
Practice Address - Phone:504-779-5515
Practice Address - Fax:504-454-7486
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03130367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00397040OtherRAILROAD MEDICARE
LA1694991Medicaid
LA1694991Medicaid