Provider Demographics
NPI:1245950708
Name:BACON, ALEKSANDRA MAIA (A-GNP-C)
Entity type:Individual
Prefix:MRS
First Name:ALEKSANDRA
Middle Name:MAIA
Last Name:BACON
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 POLK ST UNIT 303
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1995
Mailing Address - Country:US
Mailing Address - Phone:802-343-1986
Mailing Address - Fax:
Practice Address - Street 1:37 FRIEND ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-3068
Practice Address - Country:US
Practice Address - Phone:978-513-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MARN2330670363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program