Provider Demographics
NPI:1437340361
Name:BACON, NICOLE ANN (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:BACON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4972
Mailing Address - Country:US
Mailing Address - Phone:860-589-1881
Mailing Address - Fax:860-583-1512
Practice Address - Street 1:255 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4972
Practice Address - Country:US
Practice Address - Phone:860-589-1881
Practice Address - Fax:860-583-1512
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist