Provider Demographics
NPI:1578197273
Name:BACON, CAITLIN NICOLE
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:NICOLE
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4916
Mailing Address - Country:US
Mailing Address - Phone:203-380-0808
Mailing Address - Fax:
Practice Address - Street 1:263 ALDEN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-3707
Practice Address - Country:US
Practice Address - Phone:203-522-0968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program