Provider Demographics
NPI:1750741278
Name:BACON, CHRISTINA
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:RAE
Other - Last Name:BOTTOMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:18261 MANCHAC PL S
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3371
Mailing Address - Country:US
Mailing Address - Phone:251-709-6139
Mailing Address - Fax:
Practice Address - Street 1:18261 MANCHAC PL S
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3371
Practice Address - Country:US
Practice Address - Phone:251-709-6139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA129509163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse