Provider Demographics
NPI:1760789143
Name:BACON-FORD, AMY REBECCA
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:REBECCA
Last Name:BACON-FORD
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 1:1 ELLIOT WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3599
Mailing Address - Country:US
Mailing Address - Phone:603-663-3388
Mailing Address - Fax:
Practice Address - Street 1:1 ELLIOT WAY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3502
Practice Address - Country:US
Practice Address - Phone:603-663-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH072006-23363LP0808X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No282N00000XHospitalsGeneral Acute Care Hospital