Provider Demographics
NPI:1255838603
Name:L'HERAUX, CRYSTINE
Entity Type:Individual
Prefix:
First Name:CRYSTINE
Middle Name:
Last Name:L'HERAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15230 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-8107
Mailing Address - Country:US
Mailing Address - Phone:707-995-4500
Mailing Address - Fax:707-994-2401
Practice Address - Street 1:15230 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-995-4500
Practice Address - Fax:707-994-2401
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008699363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care