Provider Demographics
NPI:1336122399
Name:LACROIX, DIANE (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LACROIX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT CH 17767
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-0001
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:1 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8065
Practice Address - Country:US
Practice Address - Phone:810-606-6137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024219363L00000X
MI4704172544363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4653168Medicaid
MI4653177Medicaid
P00157330OtherRAILROAD MEDICARE
MI4653159Medicaid
DL172544OtherBLUE CROSS BLUE SHIELD
MI4653177Medicaid
DL172544OtherBLUE CROSS BLUE SHIELD
MIB56088112Medicare Oscar/Certification