Provider Demographics
NPI:1356217715
Name:BACON, NIA
Entity type:Individual
Prefix:
First Name:NIA
Middle Name:
Last Name:BACON
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 1:12227 S 33RD ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-1696
Mailing Address - Country:US
Mailing Address - Phone:973-380-3171
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1850
Practice Address - Country:US
Practice Address - Phone:402-346-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist