Provider Demographics
NPI:1295857597
Name:BACON, CHERYL FRASER (MAAC, LICAC)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:FRASER
Last Name:BACON
Suffix:
Gender:F
Credentials:MAAC, LICAC
Other - Prefix:MISS
Other - First Name:CHERYL
Other - Middle Name:ANN
Other - Last Name:FRASER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAAC,LICAC
Mailing Address - Street 1:6 GROVE ST.
Mailing Address - Street 2:# 103
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1534
Mailing Address - Country:US
Mailing Address - Phone:781-878-2667
Mailing Address - Fax:
Practice Address - Street 1:6 GROVE ST.
Practice Address - Street 2:# 103
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1534
Practice Address - Country:US
Practice Address - Phone:781-878-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA609171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist