Basic Information
| Provider Information | |||||||||
| NPI: | 1346703121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACON | ||||||||
| FirstName: | JOSIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E ORANGEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928056807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002491266 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6624 S 196TH ST STE 107 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980323113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002491266 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2019 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.