Provider Demographics
NPI:1417259565
Name:BACON, ABBY LYNN (RN)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:LYNN
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 1:202 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:RELIANCE
Mailing Address - State:SD
Mailing Address - Zip Code:57569-2024
Mailing Address - Country:US
Mailing Address - Phone:605-473-5059
Mailing Address - Fax:
Practice Address - Street 1:1323 BIA ROUTE 4
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339-1200
Practice Address - Country:US
Practice Address - Phone:605-245-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR036402163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse