Provider Demographics
NPI:1417599200
Name:BACON, CANDICE ELAINE (CRNA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:ELAINE
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 1:1404B LISCHEY AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37207-5103
Mailing Address - Country:US
Mailing Address - Phone:769-218-7115
Mailing Address - Fax:
Practice Address - Street 1:200 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1800
Practice Address - Country:US
Practice Address - Phone:502-629-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-13
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN203898163W00000X
KY3014174367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse