Provider Demographics
NPI:1912270620
Name:BACON, DRUCILLA (CRNP)
Entity Type:Individual
Prefix:
First Name:DRUCILLA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 NORTH AVE
Mailing Address - Street 2:#104
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1925
Mailing Address - Country:US
Mailing Address - Phone:330-344-3990
Mailing Address - Fax:330-634-9433
Practice Address - Street 1:33 NORTH AVE
Practice Address - Street 2:#104
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1925
Practice Address - Country:US
Practice Address - Phone:330-344-3990
Practice Address - Fax:330-634-9433
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-13312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066886Medicaid
OH0091231OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP # URGENT CARE
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH1992138028OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI # URGENT CARE
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH0066886Medicaid