Provider Demographics
NPI:1366865875
Name:BACON, RAMONA (NP)
Entity Type:Individual
Prefix:
First Name:RAMONA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7322
Mailing Address - Country:US
Mailing Address - Phone:386-424-5038
Mailing Address - Fax:
Practice Address - Street 1:401 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7322
Practice Address - Country:US
Practice Address - Phone:386-424-5038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN189981163W00000X
TN18401363LF0000X
FLAPRN9376252363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I505190Medicare PIN
TNVVJ893B288Medicare PIN