Provider Demographics
NPI:1245399930
Name:BACON, MARY MARGARITA (ARNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MARGARITA
Last Name:BACON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MERRIMACK
Mailing Address - State:NH
Mailing Address - Zip Code:03054-4123
Mailing Address - Country:US
Mailing Address - Phone:603-206-4390
Mailing Address - Fax:
Practice Address - Street 1:48 GLASS ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NH
Practice Address - Zip Code:03275-1506
Practice Address - Country:US
Practice Address - Phone:603-485-7788
Practice Address - Fax:603-485-7799
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH038972-23-03363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30341583Medicaid
NH30341583Medicaid
NHP58967Medicare UPIN