Provider Demographics
NPI:1962869016
Name:BACON, EMILY (APN-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 WOODSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079
Mailing Address - Country:US
Mailing Address - Phone:856-628-4504
Mailing Address - Fax:
Practice Address - Street 1:58 EUCLID ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-4626
Practice Address - Country:US
Practice Address - Phone:856-628-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00612800363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health