Provider Demographics
NPI:1588265615
Name:BACON, CELIANNE MARIE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:CELIANNE
Middle Name:MARIE
Last Name:BACON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39413 CHADUZA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:VALENTINE
Mailing Address - State:NE
Mailing Address - Zip Code:69201-2331
Mailing Address - Country:US
Mailing Address - Phone:402-389-1303
Mailing Address - Fax:
Practice Address - Street 1:1917 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4642
Practice Address - Country:US
Practice Address - Phone:308-398-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE113298363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health