Provider Demographics
NPI:1639517311
Name:BACON, JUDY ANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:ANN
Last Name:BACON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ROBIN HOOD RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1675
Mailing Address - Country:US
Mailing Address - Phone:912-678-1131
Mailing Address - Fax:912-871-3987
Practice Address - Street 1:11 ROBIN HOOD RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1675
Practice Address - Country:US
Practice Address - Phone:912-678-1131
Practice Address - Fax:912-871-3987
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN032393164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse